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Mental Health and the Brain: Adolescence, Attachment

Mental Health and the Brain:
A Discussion
Fall, 2008


Adolescence, Attachment Theory

Our tenth session and resulting on-line forum discussion competed a discussion of four representative instances of mental health syndromes in the context of our earlier discussions of the variety of available therapeutic procedures and of the brain. This week we move on to exploring some broader relevant theoretical perspectives in this context.

Readings for this week


Attachment Theory

Relevant recent materials elsewhere

Where we've been ...

I, for one, am less comfortable with a mental health approach that uses the ability to deal with "normative" reality" (or "tea kettle" reality) as a goal and more comfortable with one that uses, instead, enhancing the ability of individuals to conceive and revise their own individual stories. ... Paul

I am not a fan of a normative view of mental health either .... It seems to me that if in general you adopt the principle that you are going to help the individuals who want help to achieve their goals (fitting in to society, freedom from suffering, losing weight, better vision etc. ) and you do this to the best of your ability using the tools you have available, then you are fulfilling your purpose as a health care provider ... ryan g

I think taking normative measures as a goal of mental health treatment is a potentially dangerous undertaking. As I’ve mentioned before, I think the more we shape peoples’ behavior to a “norm” the more we narrow the range of acceptable behaviors and the more alienated and disenfranchised those who do not fit the mold, in one way or another, are likely to feel. Besides life is more interesting in color than in black and white alone ... Sophie F

What about someone with schizoid personality disorder, with no interest in social relationships, and very little ability to experience pleasure? Often this person won't present for treatment. Often they won't even feel dissatisfied with their status quo. But is there room for a mental health professional to say, wait, there is a potential problem here? ... ysilverman

I am all for diversity. I don't want everyone to think, talk, act, and look just like me but, for their own benefit, I do want everyone to live in the "tea kettle" reality which is dictated not by any culture but by the laws of nature (gravity pulls things down type laws) ... MartinBayer

I am uncertain about whether this is the responsibility of the storyteller or the unconscious. Certainly, the unconscious is capable of performing actions without storyteller involvement, like sleepwalking. So maybe the storyteller was never involved? Does the storyteller ever participate in tea making? .... jrlewis


Take-off points - Attachment

In essence, attachment categories do tell a story. They tell a story about how emotion has been regulated, what experiences have been allowed into consciousness, and to what degree an individual has been able to make meaning of his or her primary relationships.

-Arietta Slade

However small such effects might be, it may not do to ignore them. For one thing, there is evidence that the categories of attachment -- secure and insecure -- tend to persist and to shape the personalities of older children and young adults. In an extensive longitudinal analysis known as the Minnesota Studies, two researchers, Alan Sroufe and Byron Egeland, followed up on a group of 267 babies who had been labeled securely or insecurely attached in Strange Situation experiments (and other diagnostic tests) conducted in the mid-70's. On nearly all psychological measures -- from ego resiliency to independence to empathy to the capacity for fun -- the children who as babies had been securely attached scored highest. Teachers who knew nothing of these labels and were asked simply to evaluate the children tended to like the secure ones best. They described the avoidant ones as obnoxious and arrogant and the ambivalent ones as clingy and ineffectual. These findings do not establish a causal link, only a correlation, between security of attachment and later personality traits, and it may still be, for example, that the insecure children were simply born more aloof or fretful. But the results are suggestive, especially since they have been replicated in other studies and at later ages. And if they are accurate, then anything that increases the number of anxiously attached children ought to concern us.

-Margaret Talbot

The therapist-client relationship, like the parent-child relationship will manifest the same four characteristics described earlier: proximity maintenance (the client will seek the therapist to discuss problems), separation distress (the client will experience some degree of distress when needing the therapist and the therapist is not available), safe haven (will seek the therapist when needing help in resolving distress), and secure base (will use the therapist as a secure base to explore the inner and outer worlds of her/his life). Like the process of developing attachment that occurs in the child-parent relationship, the developing of the therapeutic relationship will follow a similar process: preattachment, attachment in the making, clear-cut attachment and goal corrected partnership. And like the patterns of attachment that emerged in the stressful Strange Situation Procedure, the natural ruptures and reunions that occur in the psychotherapy are likely to activate the attachment behavioral system. For some individuals who have had particularly untoward experiences in their family of origins, simply walking into the therapist's office is likely to cause anxiety. But in this unusual type of relationship, the client has the opportunity to have these patterns brought to their attention, reappraise their functionality and learn new methods of regulating affect.

-Daniel Jay Sonkin



Take-off points - Adolescence

Increasing evidence points to links between the timing and growth rates of specific brain areas in the young brain and the likelihood of developing a wide range of mental disorders later in life, say researchers convened by the National Institute of Mental Health (NIMH), a part of the National Institutes of Health. Included among these mental disorders are autism, anxiety, bipolar disorder, eating disorders, substance abuse, and attention deficit hyperactivity disorder (ADHD).

National Institute of Mental Health

In addition to studies of normal development and of risk factors, much additional research focuses on mental illness in childhood and adolescence and what can be done to prevent or treat it. The science is challenging because of the ongoing process of development. The normally developing child hardly stays the same long enough to make stable measurements. Adult criteria for illness can be difficult to apply to children and adolescents, when the signs and symptoms of mental disorders are often also the characteristics of normal development. For example, a temper tantrum could be an expected behavior in a young child but not in an adult. At some point, however, it becomes clearer that certain symptoms and behaviors cause great distress and may lead to dysfunction of children, their family, and others in their social environment. At these points, it is helpful to consider serious deviations from expected cognitive, social, and emotional development as“mental disorders.” Specific treatments and services are available for children and adolescents with such mental disorders, but one cannot forget that these disorders emerge in the context of an ongoing developmental process and shifting relationships within the family and community. These developmental factors must be carefully addressed, if one is to maximize the healthy development of children with mental disorders, promote remediation of associated impairments, and enhance their adult outcomes.

A report of the Surgeon General: Children and Mental Health

"Juveniles function very much like the mentally retarded. The biggest similarity is their cognitive deficit. [Teens] may be highly functioning, but that doesn't make them capable of making good decisions,"

Law professor Steven Drizin of Northwestern University in Chicago

The underlying problem in reaching a troubled teenager is clear to just about any parent of one. Adolescence is a fog, a kind of high fever. Emotion swamps reason; rumination undermines introspection. It is not an ideal time, many psychiatrists acknowledge, to perform therapy that requires the detached moment-to-moment self-awareness crucial to cognitive therapy.

Benedict Carey Pills or Talk? If You’re confused, No Wonder

Recently, there has been some concern that the use of antidepressant medications themselves may induce suicidal behavior in youths. Following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. In 2006, an advisory committee to the FDA recommended that the agency extend the warning to include young adults up to age 25.

National Institute of Mental Health



kmanning's picture

tea kettles and education

“The individual must be conceived as inserted in a network of interpersonal relations in order to define psychological phenomena.” Vpizzini.

I think this is a very good point. As we have discussed at great length in this course, everything in our life is relative, and has meaning and the ability to be defined only because we relate everything to everything else. We can NEVER think of people outside some frame of reference, some normative reality. To strive to do so may be to free ourselves from one kind of tea kettle reality, but at the same time it is merely adopting another one. Maybe it is one we have previously been unaware we believed in, but it is a normative reality nonetheless. I think it is important to recognize this fact, and to recognize that “change” as a measure of health is just as normative as any tea kettle reality. In adopting change as our ultimate criterion, this assumes we are able to look at certain behavioral characteristics of people, quantify those behaviors such that we can understand them as characteristics attributable to people, and then observe ways in which they change. We will always be making assumptions and qualifying feelings, emotions and mental states, as being one way or another, and this will always result in us believing that one way is “wrong” and one is “right.” As Adi and Ryan both recently discussed in their posts, striving to continually adopt new meaning, and to continually question one’s assumptions about life seems to me an excellent guiding force that could be at the root of mental health. To be able to realize that what one previously believed was limited and normative, and to adopt a new view of the world – which itself will be limited of course – seems an excellent goal to strive for.

Yet even as I write that, I realize I don’t even really know what that means anymore. This course has taught me so many things about how I want to change my view of my mental states, and about how I would like to strive towards my own personal new understandings, but it hasn’t really given me much of an idea about how I can interact with people who haven’t taken this course to help improve their mental health. I think a good starting off point is to find some way to make a larger audience of people actually believe some of the concepts many of us just assume to be true at this point in the course. That we create meaning; that most of what we do occurs without the involvement of our conscious mind; that conscious story telling does have the ability to affect the brain in just as powerful, if not more powerful, ways as drugs. I agree with what Yona said that everyone can benefit from therapy. However, I don’t think that having sessions with a therapist is the best way to accomplish this. I think we need to put more money/effort/legislation into getting these ideas to be part of every child’s education. If everyone in the world could take this course, I think we could greatly decrease the need for therapists.

adiflesher's picture


I think that education really is one of the best and cheapest answers that we have. 

 Paul and I have actually started working on an education project geared towards health curricula in schools.  Currently the health curricula in this country teach kids what is healthy and what is not healthy.  For example, eat your vegetables (not too much fat) , don't do drugs and don't have unprotected sex  or don't have sex before marriage - depending on the school district.   

The problem with these approaches is that they don't really prepare kids to make the tough choices that they will have to face in life. Many of these kids sit through all of these health classes and then go out smoke a joint, eat a cheeseburger and have unsafe sex.  Why?  What's wrong with our approach?

I think the main problem is that we aren't giving them a real sense of who they are, how they make choices and  the ways in which their unconscious might lead them towards certain behaviors.

Several years ago, while running a summer camp, I started experimenting with teaching kids about the brain. In little doses I started introducing it into parts of the program that I was directly running.  Right away the response was overwhelmingly positive.  

The kids were hungry to think about this stuff.  I had to cut off conversations that would have gone on for hours. Kids would approach me days later to pick up on some point that we had discussed.

I realized reason it was working was because I was opening a door for them to ask pressing questions about themselves.  Who am I? Why do I behave the way I do? Why might other people behave the way they do?  

These were not abstract academic discussions, these were urgent pressing issues to the teens I worked with.

I think that we need to teach kids about their brain and empower them as moment-to-moment investigators of their own consciousness and creators of their own stories.   


jrlewis's picture

I really like your thoughts

I really like your thoughts about education.  I totally agree that children should learn about themselves and their brains. In fact, I would argue that neurobiology and psychology are a special set of intellectial activities.  They are self-reflective; the brain studying itself.  This leads to unique concerns about the subject-object duality.  The issues and lessons learned might result in more self-aware or self-reflective adults.  

adiflesher's picture

My Definition of Mental Health

My definition of mental health – is agrowing moment-to-moment awareness of the three loops (self-world, conscious-unconscious& intrapersonal) coupled with an ability to effectively integrate insightgained from the three loops into over-arching narratives – without sacrificingthe constant access to new insight brought by moment-to-moment awareness.  I also believe that compassion (love) for oneself and others is both a natural outgrowth of this type of awareness as wellas a useful tool for achieving it.

This definition is not prescriptivein nature. We don’t have an end goal – or a platonic vision of health to whichwe aspire. 

Let’s use Ryan’s example of the bankerwho had a psychotic break and started drinking. Perhaps the banker had spent alifetime repressing his desire to be a kindergarten teacher. Perhaps losingmoney in the market put him in touch with this deep desire. Perhaps drinkingwas the only way to avoid dealing with the fallout that would cause in hiscurrent life. Or perhaps he his father was an alcoholic and he spent his wholelife running away from the emotional pain caused by their relationship – only tohave it catch up with him when the market crashed. Perhaps he was cheating onhis wife and the guilt drove him to drink.  

The point is I don’t know any ofthis when he walks in my door asking for help. Nor can I know what he should doto improve his life. My sense is that often in these types of situation theperson asking for help doesn’t know either.

So how can we help?  As a mental health practitioner I would twothings. First if I thought he was an immediate danger to himself or others Iwould intervene.  If that wasn’t the caseI would try to help the banker find the moment to moment awareness to engagehis three loops.

Can he become more aware of hisemotions – especially prior to drinking? What can he learn from the conflictgenerated by his drinking?  Whatconflicts are going on in the interpersonal realm? 

Built into this approach is anassumption that people are trying to do the best that they can with the toolsand information that they currently have at their disposal. The idea is that byenhancing their capacity to closely observe the loops we give them a chance tosearch out alternative solutions and meanings. These are not our solutions andmeanings for them, but the outgrowth of their ability to know themselves in a deepand powerful way in each moment. 

 I will also add – that as a practitioner – I wouldtake seriously the idea that I should constantly be engaging in the three loopsand open to all the new information that they offer me – both as a person andas a practitioner.   

ryan g's picture

A further suggestion

I really like some of the new platforms upon which people have been suggesting that we move forward.  Taking more consideration for the individuality of each person, encouraging growth no matter where the patient is starting, and facilitating the ability to live up to potential.   These all seem to me to be less wrong than where we started and less-wrong than the current model that is used in most of healthcare today. 

However, I have one little bone to pick with these models.  Thinking of mental health and its treatment as a journey or a process, to me, implies that there is a destination or eventual goal.  In my mind this becomes an issue.  If we are going to measure the success of something by the amount of change, then we have to define which direction the change moves.  It's not satisfactory to say that it is a journey without direction.  

For example, take two hypothetical patients.  First, a previously happy, "healthy" banker has a psychotic break because of the current economy, gains 75 pounds, takes up drinking, and leaves his wife and kids.  Second, an insomniac who finally gets his sleeping habits in order and begins sleeping through the night.  I think most people would argue that patient one has experienced a greater change in his life.  I also think most people would argue that patient two has moved in a healthier direction than patient one.  

My point is that with the journey model of mental health, we eventually run into the same problems that we had before.  As healthcare providers we are defining, arbitrarily, where it is we want our patients to go.  It doesn't matter if you define that as "fulfilling their personal potential."  We are still defining what that potential is.

I would like to suggest a solution to this problem.  What if, instead of adopting change and growth as the cornerstone of our new model of mental health, we adopted acceptance?  So, as healthcare providers, instead of encouraging patients to push forward towards some arbitrarily defined goal or potential, we encourage them and help them to accept and find peace in their current condition.  The real attraction of this idea, for me, is that it allows us to transcend the need to set a goal or define a duality of "there vs. here."  It is just "here."  

Just to be clear, I am not suggesting that we encourage patients to suffer.  As I understand it, change is an inherent characteristic of our brains.  It's going to happen no matter what a patient or physician does.  I wonder what would happen if patient and provider stepped back and allowed the change to happen on its own instead of trying to shape it into desired pathways.  

I acknowledge that this does not move us any closer to solving the practical issues of how to change a broken healthcare system (costing etc.).  If nothing else, maybe acceptance could be used as a first step to facilitating some other desired change.  That is, if a patient fully accepted their condition, maybe it would help other changes come about more elegantly.  



Sophie F's picture

Maybe mental health is a

Maybe mental health is a human project and not a healthy/ill dichotomy. Maybe we should operate on the premise that everyone needs “help.” If there were consensus that everyone has the potential to be a “better” version of oneself than some of the stigma associated with experiencing distressing mental states and seeking help would dissipate. If mental health is not static, but a process of a ever-refining one’s story, so as to maximize one’s potential then the necessity of reducing a person to her behavior, her symptoms, her “limitations” would cease to be relevant and each of us would be less inhibited in the process of honing our skill sets, coming up with a “tool kit” of sorts that is tailored to our individual genes, our individual experiences.

I found the discussion about “reciprocity” in health care intriguing. I think, too often, the inherent dynamism of the doctor and patient relationship is not acknowledged and utilized to its fullest. It was suggested in class that the patient affects the doctor, who affects the patient and then back around… If mental health were less geared towards the mental health worker “affecting” the patient, changing her, there might be some room left over for the reality that we are all affected by each other. I don’t think the goal of mental health should be to “change” someone, but to facilitate exploration and enable agency, choice, by unburdening the individual of story-telling features that may not be constructive for that individual. “Help” does not have to come in the form of a defined beginning and set of endpoints to measure “success,” rather can be an ongoing process or project. Sometimes people may not “want” help or even be aware that they are experiencing internal conflict, in which cases, it is ever more necessary to employ the dynamic relationship between mental health worker and patient, in order for the mental health worker to assist the individual in achieving goals that she herself may have yet to articulate. We trust physicians to be “experts” in other areas of the body, where symptoms and treatments are equally vague as with mental health. Why can we not trust that sometimes someone on the outside has a clearer vision than the person on the inside?
mstokes's picture

I appreciate the angle

I appreciate the angle you've brought to the discussion here, Sophie--and I wonder what this looks like from a practical standpoint.  How can a mental health worker enter into a conversation with a "patient" not expressly seeking help--will that patient ever engage in the services for a mental health care work?  Or, when the patient is expressly seeking help, how can the physician or worker help them evolve from their position as pure patient to one as helper/worker/enabler?  How does this shift fit with the final question--why we can we not trust someone on the outside as having a clearer vision than the person on the inside--as we trust physicians in their diagnosis of medical issues, even when we don't detect them ourselves--which does suggest that the phsycian has a perspective that will help the patient to find more help and clarity than without?  Perhaps this also goes to Yona's earlier assertion that everyone could, in fact, (however practical or not) benefit from mental healthcare.   

Does it all then go back to the necessity of a cultural change, which changes how we view mental healthcare, so that it can become a dynamic continuum, part of an ongoing conversation, which incorporates "reciprocity" and which doesn't necessarily have a defined beginning and end, but one where better stories are constructed toward more productive and satisfying ends?   How do se keep such a relationship moving towards productive ends, not introducing a system where mutual benefit creates an unhealthy reliance on the other?  Or will a relationship which functions around these ideals always leave the door open for this mutual reciprocity?  Our close relationships in our everyday lives do not have a finite end point in mind; would it follow, then, that a patient and mental health worker's relationship should also not have a defined end (and as such, is that practical)?  Or would we be imposing on the patient/mental health care worker relationship expectations better left to natural relationships elsewhere in life?

 I didn't mean to raise so many new questions--questions that may not have been at all implied in your comments--but I appreciate all that you've set me off to thinking about!   

akerle's picture

  I think that in our


I think that in our search for a definintion of mental health we are ignoring something critical. A great number of us assume that the individual in question KNOWS what their life goal is and better yet, has a more complete understanding than anyone else out there (doctor, friend, family).

The 'ideal' of health is by nature an aspiration and many people live their lives aspirationally. We live trying to be the best in a highly competitive society and competition would not function without the notion of some 'ideal'. It may take an individual years, if ever, for them to really listen to what they want and then to take charge of that feeling and channel it into a way of life. What I'm trying to say is that asking someone to listen to their storyteller may be easier said than done and constructing a mental health system based on this notion overlooks the complex way that people understand themselves. So yes, from a perspective of a mental health professional it would be ideal to judge each case from a unique perspective with the interests of the patient as the number 1 priority. What happens though, when the interests of the patient are conflicting and unsure? When even they do not understand what it is they want.

I just want to argue against putting too much pressure on any one individual or groups of individuals. That the dichotomous relationship between patient and doctor, individual desire and societal desires, should be challenged because putting too much trust in one negates the presence and possible benefit of the other.  I don't believe notions of mental health can be entirely individualised because, as we have discussed previously, nobody lives in complete isolation. We are constantly interacting with eachother. Yet, as we have also discussed indepth, society can damage the ways in which we relate to ourselves and to others and social norms can prevent individuals from living in the best possible way for themselves. So each relationship between doctor and patient may have to be unique, but I do not believe that a person, by benefit of being the one in control of his/her life, necessarily has the ability to understand themselves better than someone on the outside.

jrlewis's picture

Another Metaphor

In order to address the challenge of coming up with a model of mental illness, I would like to collapse the health-illness duality.  Hopefully, this will eliminate the need to establish a normative reality.  Instead, I would like to discuss the relationship between a person and their life.  The idea, that a human life can be considered an artwork, was suggested by my philosophy professor, Michael Krausz.  I would like to expand this metaphor further… Life can be both a creative process and a creative product. 

A human life can be considered an artwork or a series of artworks.  The artist is the human living a particular life, creating a unique work of piece.  This piece is based on the person’s own experiences, feelings, and talents.  Others can contribute to this piece by acting as muses and teachers knowledgeable about different techniques.  These are the roles that I would have doctors, physical and psychological play.  The goal is simply for the artist to continue contributing artwork to the community.  The sum of the art objects or artwork, the product, is the complete life of a person. 

The concept of artwork appeals to me because of the similarities between art and health.   Artwork, like life, is very tricky to evaluate because of differences in cultural contexts and interpretative practices.  

Student's picture

mental heath definition...

One of the definitions Adi lent us was, ""A desire to be in charge of our own lives, a need for control, is born in each of us. It is essential to our mental health, and our success, that we take control."  I thought that it is this desire for control, and the ability to control, that really defines true mental health.  I also think that a lack of control is where the stigma for mental health comes from... the fear of the uncontrollable.  I think it's the surprises and the unpredictability that can make something uncontrollable so scary.  If our brains can control our subconscious and our conscious, but we're only aware of our conscious, is the subconscious what really defines us? Our conscious' are out there, exposed to the world. We're functionally in society as a result of our conscious'.  But, our subconscious, how controlled it is, how much unpredictability lies there, how much crosses over to our conscious state- could that in part define the role we play in society, and how likely we are to be "uncontrollable?"
adiflesher's picture


I find myself agreeing with thisidea that control plays a role in mental health. People who are completelydominated by their emotions and have no ability to regulate them tend to suffera great deal and also create a lot of turmoil for other people around them. Incontrast people who are overly in control (or repressing) their emotions tendto suffer a lot as well and to cause pain to other people around them.

The trick is to find a middle groundbetween these two extremes.  A placewhere we are neither controlled by our emotions or stifling them to the pointthey cease to be effective tools for interacting with the world.  

Ljones's picture

I agree, but...

I agree that this definition (that health is individual etc) is probably the least wrong definition that we have come up with this semester, but I'm not sure if it helps our broken mental health system at all. If everyone is individual, how do you help them cost effectively? How do you know how to help them at all? How do you even know WHEN they need help?

I understand and agree with the logic that what is (mentally) healthy for one person could be unhealthy for another, but how can we change the current system to be able to work in this new paradigm? 

vpizzini's picture

I completely agree with

I completely agree with Paige. I also believe that it is impossible to come up with a universal definition of mental health. People differ from one another in their intelligence, desires, feelings and behaviors, in their views of themselves and the others, and in their views of the world and the future. We cannot just categorize the differences among people without considering how the different parts of each person come together to make that person who she/he is.

Modern research seeks the reason for every personality and every possible pathological evolution of our being in relation to the others. The individual must be conceived as inserted in a network of interpersonal relations in order to define psychological phenomena. Personal experiences, even in the early infancy, are frequently considered when particular pathological conditions are manifested, in order to justify the modalities of action of an individual.Thus, we should move forward from a simple description of the symptoms and the idea of a single isolated subject.

At the beginning of this course, my definition of mental health was based on the distinction between what can be considered normal and abnormal. The label“abnormal psychology” suggests that we should start with a conception of normalcy and then define mental illness as variations that are not normal.However, something can be an illness even if it is a normal occurrence, and things could be abnormal without being illness. 

We all have different experiences and we all respond to external stimuli in different ways.

ysilverman's picture

Fascinating NYTimes Obituary ...

About H.M., who lost the ability to form new (conscious) memories in his 20s ... though his ability to learn things in "unconsciously" remained.

 H. M., an Unforgettable Amnesiac, Dies at 82

"Every time H. M. performed the task, it struck him as an entirely new experience. He had no memory of doing it before. Yet with practice he became proficient. 'At one point he said to me, after many of these trials, ‘Huh, this was easier than I thought it would be,’ ' Dr. Milner said."

Here is someone who lived almost an entire lifetime without the ability to form any sort of coherent narrative ... 


PS2007's picture

We have spent many of our

We have spent many of our sessions talking about finding a definition of mental health, and while we have not found one we have been able to have many great discussions about this issue.  

It seems to me that it is impossible to come up with one universal definition, and that maybe the definition of mental health changes with each person.  Maybe instead of defining mental health we need to be educating doctors to spend more time communicating with their patients and let the patient define the issue, not the doctor.  

While obviously this would create many problems within our health system as it is now, it seems to me the best solution for respecting each person's unique mental health experience.  Maybe if we focus on changing the system we will be more able to define mental health as our perspective on it changes.  

Martin's picture

Diseases of the soul are

Diseases of the soul are more dangerous and more numerous than those of the body. ~Cicero

... I love this quote…. Our ability to get things wrong intellectually is infinitely greater and more probable than for us to get things wrong physically… It is just easier to ignore the intellectual failings. Unrelenting Skepticism, in my understanding is a denial of our ability to recognize that we have a disease of the mind. Which leads me to a quote from one of my favorite films. “The greatest trick the devil ever pulled was convincing the world he didn’t exist.” This is all akin to a point I made earlier about calling things that are problems, not problems; and then saying we have dealt with the problem.

1) Certainly, what each person himself thinks of (his personal phantasm) as the tea-kettle reality is nothing more than “a set of unconscious understandings that also varies from person to person”. BUT that does not mean that the ontological reality to which the person is pointing with these personalized thoughts, ideas, and descriptions is itself nothing more than these personal thoughts, ideas, and descriptions.

So, my ideas and descriptions of the “teakettle” might be different from yours but the tea kettle we are both failing to describe is the same and it can’t be anything but that or else when we talk to each other about the world we are speaking of ontologically different things by using similar names when what we think we are doing is using different names to describe the same ontological reality.

To give up the notion that we are all pointing at the same thing is, in my mind, to acknowledge that there is no reason for us to talk to each other at all since we have nothing in common with each other.


2) Health, either bodily or mental, is best described as an activity and not a static state of being in a particular disposition or orientation. I think our discussion thus far has led us to that fact, unambiguously. But, the path we have taken to get there has diverged into the “teakettle people” and the “no teakettle people”. That difference does color the meaning of our definition as health as an activity. 

What this means coming from a teakettle person’s perspective is something like this:

Health, as an activity, is an excellent activity/ a virtue. (See Aristotle’s Ethics, book 2 or 3 I think) Virtues/one’s degree of excellence is measured by growth. For example, a fat slothful person who learns to exercise has cultivated his health in a way that an average person (Just because you're not sick doesn't mean you're healthy. ~Author Unknown) who does not exercise has not.  Repeated activity/formation of a habit leads to “healthy activity” or “well functioning” in a way that is not characteristic of individual acts/ or states.  This view of health allows us a tremendous amount of leewaywhen we are naming things healthy or unhealthy. We need not even say that allfat people are “unhealthy”. 

This definition of health I think is legitimate fruit of our semester's labor and certainly less wrong than most of my earlier thoughts.  

ryan g's picture

As a no-teakettle person, I

As a no-teakettle person, I want to respond to the point that if there is no tea kettle reality, there is no point in talking to each other because we have no common ground.  

To be sure that I was understanding you correctly, it seems like you were saying that we all have our inherent sets of beliefs and meanings that you acknowledge is not tea-kettle reality.  However, all of our individual tea kettles are pointing towards some ultimate reality that represents the true meaning of things and our goal should be to endlessly strive to make our set of beliefs and judgements more congruent with that ultimate reality.  

Here's where I agree and disagree with you.  I do think that there is that ultimate reality that we are all trying to explain.  However, I don't think that that ultimate reality has an inherent set of meaning to it.  I would say, it just exists and all meaning that is assigned to it is done by us.  

Therefore, for us to discuss mental health, all that is necessary to exist is the set of behaviors and symptoms we observe.  From there, we can and do argue over what things mean.  However, in my mind, we just need to acknowledge the fact that any conclusions we come to are not a product of the inherent meaning of that behavior but instead they represent our own interpretations of it, and as such they carry with them the flaws associated with our judgements.  

Going off on a bit of a tangent... I fully acknowledge that this is not a very useful set of thoughts for addressing issues such as healthcare policy and mental health parity.  Also, as a future physician, I don't think it would be very good for business to go around telling my patients I don't actually believe there is any such thing as health.  

Because of this, I will definitely engage in learning and applying sets of meanings.  Indeed, I plan on spending the next several years learning the version the AAMC wants me to learn.  I'm not saying they are worthless.  The important thing, in my opinion, is to keep it always in mind that this is and always will be only one interpretation.  

ysilverman's picture

In class I wasn't able to

In class I wasn't able to express this succinctly, but I think both that:

A) There is no tea-kettle health, or even a tea-kettle system of healthful activities. 


B)  I agree that health is a journey (as nobody can ever reach the pinacle of even their own personal health capabilities, if such a thing could exist). 

In the second sense, B, I think we are in agreement in terms of health both physical and mental. It is from this end that I suggested, earlier in the semester, that everyone could benefit from therapy (theoretically, always). I mean this not in a practical sense, as I do see this as being cost prohibitive, and perhaps not the best use of state dollars (see NICE in Britain), but in the perfect sense: I think we are all, always, in a place that could be better, that we could always grow psychologically. 

It seems to me that we have come to a place where the goal of mental health is to continue working towards a self-actualizing life. What a "self-actualized" person looks like is immaterial but a trip towards psychological health would be one towards expressing one's own individual capacities in the fullest possible way. In thinking of health this way, we are allowing for the treatment of people who do not believe they need treatment, and for people who ask for things in treatment we can't/won't provide them with. In this sense, the truest roadblock to actualization is a refusal to explore things that hold one back. That whole unexamined life thing ...

I think that equally true in this process is accepting one's limitations, whether due to birth, history, and/or circumstances/luck, and forging on. To the person who asks us to make them a cheerleader/queen of England/America's Next Top Model we say that the job of a doctor/mental health professional isn't to make a person any one thing, but to help them get wherever they are going. A therapist/mental health professional can never get a person anything, whether we believe it important or not. (Even if a lonely kid asks for friends, not cheerleading ability and popularity, even the best mental health practitioner can't make them appear out of thin air ...)

I think this is one of those things that works better when you consider it in a personal way than in a broad sense, and I think, to a degree, being a good mental health practictioner means just that: thinking about each person in his or her own way, and treating each as such. It is also about increasing a person's own ability to make choices: the problem with agoraphobia, for example, isn't that a person is functioning outside of society, but that he or she feels unable to do otherwise. The problem with mania isn't mania, but rather that it prevents a person from expressing themselves as fully as they can/may potentially limit his or her agency. A goal for treatment isn't about the "problem" but about the "person", not as separate from such. Not, how do I cure mania, but how do I work to help this person lead a life as full as possible, within their natural born gifts and constraints. 

Paul Grobstein's picture

Mental health, realities, and change

Given that we're getting close to the end of the semester, it seems appropriate indeed to be looping back to where we started, to a fragmented mental health system and the apparent need to come up with a more coherent and useful definition of mental health. Adi's list is interesting, but none of the people on it had the benefit either of knowing about contemporary work on the brain nor of a semester's exploration of a variety of mental health phenomena. Given that, we ought to be able to come up with something ... less wrong?

I actually think we've been making progress in that direction, with at least small steps every Monday session, including our last one. And that, interestingly, they are beginning to suggest one can indeed find a place to start "without defining a tea kettle reality."

Marty's point Monday evening seems to me an important one in that regard. We all have our own largely unconscious and somewhat different notions of what "mental health" is, and verbalizations of it are always incomplete approximations. Ryan (and Sophie's) idea that mental health workers should "help the individuals who want help to achieve their goals" is a good case in point. The underlying ideas, that "mental health" is individualized rather than stereotyped (one size fits all) and needs to include some considerations of individual agency, seem to me important ones consistent with our discussions of a variety of particular situations. At the same time, they fail to capture unconscious feelings many of us have about additional situations, particularly the person who doesn't ask for help but seems for some reason to need it, and the person who asks for a kind of help that we are, for one reason or another, disinclined to provide them.

It is, perhaps, because of these sorts of additional issues that one feels a need to appeal to some kind of "tea kettle reality." But "tea kettle reality" is, I suspect, itself nothing more (and nothing less) than a name for a set of unconscious understandings that also varies from person to person. Just like "normative reality" it has, for any given set of people, some similarities and some differences, so one can't ever be sure "tea kettle reality" is well defined and fully agreed to. At least as importantly "tea kettle reality," just like "normative reality," has the additional problem that it too tends to encourage a one size fits all approach, ignoring the possibility that an individual (Einstein?) might in fact have a "tea kettle reality" understanding less wrong than the existing consensus.

So where could one start in thinking about mental health without either "normative" or "tea kettle" reality? Perhaps with the notion that all humans are engaged in an ongoing creative process of making sense of the world and their place in it, and that human well-being (both individual and collective) is measured not by proximity to any particular ideal state but rather by the efficacy of that process itself, not by where one is at any given time but rather by change over time, by the ability to detect problems and create new ways of dealing with them?

Such a starting point is appealling not only because it values individual variation but also because it makes sense is terms of what we know (or currently think we know) about the brain, that it is organized to look for and make productive use of conflict (including conflict about what constitutes either "normative" or "tea kettle" reality).

What I also find appealing about such a starting point is that it obviates the need to make a sharp distinction between "health" and "illness." Yes, indeed, we all hold "dual citizenship." We all have some ability to engage in a "ongoing creative process of making sense of the world and our place in it" and some deficiencies along those lines. And so the issue isn't who is "ill" and hence needs help and who isn't and so doesn't. The issue is instead "reciprocity," as it emerged form the discussion of attachment theory: what can others do for me to enhance my ability to engage in the creative process and what can I do for others? The answers will, as seems to me appropriate, be highly individualized, fully contingent on where one is/others are rather than determined by any pre-existing fixed story.

None of this denies the usefulness of "tea kettle reality", nor of "normative reality" for that matter. But it does reposition them in an interesting way. "Normative" and "tea kettle" realities are not prescriptive ideals but rather starting points, tools that can be used up to the point where they prove inadequate, at which point they become part of the conflicting grist from which new realities are conceived. Maybe that's what distinguishes in a useful way "mental health" from "medicine" in general? That it is largely about stories, and the ability of stories to promote ongoing change?

Perhaps instead of giving adolescents special dispensations to explore an effective mental health system would encourage everyone to be continuing explorers? And it would give people a secure attachment to ... change, and to the role their own unconscious understandings, however imperfectly verbalized at any given time, play in change both of stories and of the unconscious understandings themselves?

Paul B's picture

Another 180 degree turn on my part...

I see how “tea kettle” reality is often not appropriate in approaching mental health for most cases… since there are so many limits, there really isn’t a universally accepted tea kettle reality. There’s only the collective reality of the majority, which Einstein has shown can be mistaken.

I see that it's not society's imposed criteria that determine's one's mental state (or well-being) but it is the individual himself who determine's whether he is mentally sound or not.

Paul B's picture

In Defense of the Tea Kettle Reality

As we've discussed in class, there are a very limited amount of behaviors that reflect an 'unhealthy mind' which are universal and cross-cultural. Ryan's example of suicide gives good evidence to this.

However, I think it's important to find universal traits of mental illness. The example given was of the individual with SZD whose hallucinations distracted him from warming his tea. Yadda yadda yadda, his building burns down. I would think that this would be universally recognized problem that originated from an 'unhealthy' mind. Such universal examples provide a foundation for defining and understanding mental health. Without defining a tea kettle reality, where do we start?

merry2e's picture

Where to start?

The list...a bit overwhelming...about how I feel of the definition of mental health. Thanks Adi for the post. I think I am more confused now than I was to begin with and that is ok...

"Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place." ~Susan Sontag, Illness as Metaphor, 1977


like this one...speaks to culture, the individual, the relationship of self to other...self to unconscious...etc...

adiflesher's picture

Defining (Mental) Health

Having resolved to take seriously Paul's assignment to come up with a definition of health AND taking seriously Martin's statement that there is SOMETHING out there that we all think off when we think of health (mental and otherwise), I have compiled a long list of quotes about health. Maybe in this disjointed and contradictory list, we can find the building blocks of a definition; or perhaps just a good laugh.

Defining Mental Health:
"A desire to be in charge of our own lives, a need for control, is born in each of us. It is essential to our mental health, and our success, that we take control."

Robert F. Bennett

"Early to bed, early to rise, makes a man healthy, wealthy and wise"
Benjamin Franklin
"Leave all the afternoon for exercise and recreation, which are as necessary as reading. I will rather say more necessary because health is worth more than learning."
Thomas Jefferson quotes
Love, joy, and peace cannot flourish until you have freed yourself from mind dominance.
Eckhart Tolle
It is no measure of health to be well adjusted to a profoundly sick society.

"To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life."
William Londen quotes
"Every human being is the author of his own health or disease."
"To wish to be well is a part of becoming well."

"A man's health can be judged by which he takes two at a time - pills or stairs."

Joan Welsh quotes

"Wisdom is to the soul what health is to the body"

De Saint-Real quotes

"The healthy man does not torture others - generally it is the tortured who turn into torturers"

-Carl Gustav Jung quotes

"Liberty is to the collective body, what health is to every individual body. Without health no pleasure can be tasted by man; without liberty, no happiness can be enjoyed by society."

-Thomas Jefferson quotes

"The best preservative to keep the mind on health is the faithful admonition of a friend."

-Francis Bacon, Sr.

Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. ~World Health Organization, 1948

The power of love to change bodies is legendary, built into folklore, common sense, and everyday experience. Love moves the flesh, it pushes matter around.... Throughout history, "tender loving care" has uniformly been recognized as a valuable element in healing. - Larry Dossey

Health nuts are going to feel stupid someday, lying in hospitals dying of nothing. - Redd Foxx

As a people, we have become obsessed with Health. There is something fundamentally, radically unhealthy about all this. We do not seem to be seeking more exuberance in living as much as staving off failure, putting off dying. We have lost all confidence in the human body. ~Lewis Thomas, The Medusa and the Snail, 1979

In order to change we must be sick and tired of being sick and tired. ~Author Unknown

The best six doctors anywhere
And no one can deny it
Are sunshine, water, rest, and air
Exercise and diet.
These six will gladly you attend
If only you are willing
Your mind they'll ease
Your will they'll mend
And charge you not a shilling.
~Nursery rhyme quoted by Wayne Fields, What the River Knows, 1990

Be careful about reading health books. You may die of a misprint. ~Mark Twain

The... patient should be made to understand that he or she must take charge of his own life. Don't take your body to the doctor as if he were a repair shop. ~Quentin Regestein

Diseases of the soul are more dangerous and more numerous than those of the body. ~Cicero

To feel keenly the poetry of a morning's roses, one has to have just escaped from the claws of this vulture which we call sickness. ~Henri Frederic Amiel

Fresh air impoverishes the doctor. ~Danish Proverb

The I in illness is isolation, and the crucial letters in wellness are we. ~Author unknown, as quoted in Mimi Guarneri, The Heart Speaks: A Cardiologist Reveals the Secret Language of Healing

In minds crammed with thoughts, organs clogged with toxins, and bodies stiffened with neglect, there is just no space for anything else. ~Alison Rose Levy, "An Ancient Cure for Modern Life," Yoga Journal, Jan/Feb 2002

My own prescription for health is less paperwork and more running barefoot through the grass. ~Leslie Grimutter

In a disordered mind, as in a disordered body, soundness of health is impossible. ~Cicero

Health is a state of complete harmony of the body, mind and spirit. When one is free from physical disabilities and mental distractions, the gates of the soul open. ~B.K.S. Iyengar

Sickness is the vengeance of nature for the violation of her laws. ~Charles Simmons

A healthy body and soul come from an unencumbered mind and body. ~Ymber Delecto

Our body is a machine for living. It is organized for that, it is its nature. Let life go on in it unhindered and let it defend itself, it will do more than if you paralyze it by encumbering it with remedies. ~Leo Tolstoy

Disease is somatic; the suffering from it, psychic. ~Martin H. Fischer

An imaginary ailment is worse than a disease. ~Yiddish Proverb

Health is a large word. It embraces not the body only, but the mind and spirit as well;... and not today's pain or pleasure alone, but the whole being and outlook of a man. ~James H. West

Hear your heart. Heart your health. ~Faith Seehill

From the bitterness of disease man learns the sweetness of health. ~Catalan Proverb

If man thinks about his physical or moral state he usually discovers that he is ill. ~Johann Wolfgang von Goethe

An illness of the mind is an illness of the body, and vice versa. ~Madrianne Arvore

Just because you're not sick doesn't mean you're healthy. ~Author Unknown

When an illness knocks you on your ass, you should stay down and relax for a while before trying to get back up. ~Candea Core-Starke

The part can never be well unless the whole is well. ~Plato

The scientific truth may be put quite briefly; eat moderately, having an ordinary mixed diet, and don't worry. ~Robert Hutchison, 1932

To avoid sickness eat less; to prolong life worry less. ~Chu Hui Weng


The mind has great influence over the body, and maladies often have their origin there. ~Moliere

Live in rooms full of light
Avoid heavy food
Be moderate in the drinking of wine
Take massage, baths, exercise, and gymnastics
Fight insomnia with gentle rocking or the sound of running water
Change surroundings and take long journeys
Strictly avoid frightening ideas
Indulge in cheerful conversation and amusements
Listen to music.
~A. Cornelius Celsus

Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use only the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place. ~Susan Sontag, Illness as Metaphor, 1977

Half the modern drugs could well be thrown out the window, except that the birds might eat them. ~Martin H. Fischer

How sickness enlarges the dimension of a man's self to himself! ~Charles Lamb,Last Essays of Elia

A bodily disease, which we look upon as whole and entire within itself, may, after all, be but a symptom of some ailment in the spiritual part. ~Nathaniel Hawthorne, The Scarlet Letter

If you resolve to give up smoking, drinking and loving, you don't actually live longer; it just seems longer. ~Clement Freud, The Observer, 27 December 1964

If you do everything you should do, and do not do anything you should not do, you will, according to the best available statistics, live exactly eighteen hours longer than you would otherwise. ~Logain Clendening

May you live as long as you are fit to live, but no longer! or, may you rather die before you cease to be fit to live than after! ~Philip Dormer Stanhope, 1749

It's no longer a question of staying healthy. It's a question of finding a sickness you like. ~Jackie Mason

Health is merely the slowest way someone can die. ~Author Unknown



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