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Three organizations dedicated to helping address the youth mental health crisis in the United States will be awarded $5.3 million in grants.

The inaugural recipients include The Jed Foundation, the National Alliance of Healthcare Purchaser Coalitions’ Path Forward initiative, and the Think:Kids & Meadows Mental Health Policy Institute (MMHPI) partnership.

The Jed Foundation, which focuses on emotional health support and suicide prevention for adolescents and young adults, plans to use the grant funds to create more partnerships with high schools, colleges, and universities in support of student mental health.

 “We are extremely grateful to receive The Goodness Web’s inaugural grant that fortifies and expands our ability to increase our programming to support youth mental health and suicide prevention nationwide,” said JED CEO John MacPhee in a press release. “Our goal is to partner with more than half of the country’s colleges and universities and more than 1000 high schools to implement a mental health culture of caring that improves well-being and reduces risks for suicide for their more than 13.2 million students.”

The Path Forward, a National Alliance of Healthcare Purchaser Coalitions initiative, focuses on using large employers to drive insurance companies to cover integrated mental health treatment costs in primary care settings. The initiative will use the funds to help create and build national infrastructure supporting greater access to mental health care.

 “Employers overwhelmingly identify the need to improve access to effective, affordable, and timely behavioral health care as a top priority,” said National Alliance of Healthcare Purchaser Coalitions about The Path Forward. “Five evidence-based reforms can dramatically improve early detection and access to more effective behavioral health care. The Path Forward’s goal is implementation of these reforms.” These reforms include measurement-based care, mental health parity compliance, tele-behavioral health, collaborative care, and network access.

The grant funds will also support the partnership between Think:Kids, an organization dedicated to helping clinicians, parents, and educators work more effectively with children who have behavioral challenges

; and MMHPI, an organization dedicated to driving equitable systemic changes in Texas to provide all individuals with access to effective behavioral health care.

 The organizations will use the grant funds to develop the evidence-based Collaborative Problem Solving (CPS) approach to working effectively with children who have behavioral challenges.

 “We are thrilled and honored to be among the inaugural grantees of The Goodness Web,” said Think:Kids said in a tweet. “We look forward to partnering with [MMHPI] supporting #MentalHealth for youth.”

The grants are being awarded by The Goodness Web (TGW) in collaboration with more than 70 donors. They will award $1.7 million in 2022, with additional funds to be distributed over the next 4 years totaling $5.3 million.

“Today, mental health support is highly fragmented and largely ineffective,” said Jan Swartz, co-founder of TGW, in a press release. “TGW looks to encourage next-level collaboration among mental health donors and nonprofits so that we can have a larger, faster impact in helping our youth. We believe better support for youth mental health is one of the greatest needs of our age.”

1. The Goodness Web Foundation names inaugural grant recipients, awarding $5.3 million to accelerate initiatives addressing the youth mental health crisis. The Goodness Web. News release. July 26, 2022. Accessed August 3, 2022. 

https://www.thegoodnessweb.org/july-26-2022-inaugural-grant-recipients

2. The Jed Foundation (JED) awarded 1.5M inaugural grant from The Goodness Web. The Jed Foundation. Press release. July 26, 2022. Accessed August 5, 2022. 

https://jedfoundation.org/news-views/the-jed-foundation-jed-awarded-15m-inaugural-grant-from-the-goodness-web/

3. The Path Forward for mental health and substance use: health equity for all Americans. National Alliance of Healthcare Purchaser Coalitions. March 26, 2021. Accessed August 5, 2022. 

https://higherlogicdownload.s3.amazonaws.com/NAHPC/3d988744-80e1-414b-8881-aa2c98621788/UploadedImages/One-Page_Path_Forward_Summary_03_26_21_LW_1318.pdf

4. Kids with challenging behavior are tragically misunderstood. it’s time for a more compassionate and effective approach. Think:Kids. Accessed August 5, 2022. 

5. Our mission. Meadows Mental Health Policy Institute. Accessed August 5, 2022. 

6. @ThinkKids. “We are thrilled and honored to be among the inaugural grantees of The Goodness Web. We look forward to partnering with the @MeadowsInst in supporting #MentalHealth for youth. Learn about The Goodness Web and the grantees: 

Inaugural recipients will use funds to support infrastructure, student mental health, and programs for children with behavioral challenges.

$5.3 Million in Grants Awarded to Address Youth Mental Health Crisis

Despite the prevalence of disability, chronicity, morbidity, comorbidity, and premature mortality associated with MDD, most individuals with MDD receive inadequate treatment, if any. Members of low-income and minority populations are especially unlikely to receive treatment. But even in high-income countries, the World Mental Health Survey Initiative showed that only 22% of all individuals with 12-month MDD received minimally adequate treatment.

 Several factors contribute to this lack of treatment, including stigma about mental health in general and mental health care in particular, lack of knowledge about treatment availability and effectiveness, and the shortage of mental health providers both globally and in the United States.

In addition, out-of-pocket expenses may be prohibitive for individuals. Even for those with mental health insurance, it is increasingly difficult to find a provider, especially a psychiatrist, who accepts insurance. Clinicians who do accept insurance often have long waiting lists with available times that do not work for individuals with children or jobs.

Thus, unmet needs include increasing efforts to destigmatize mental health and its treatment; educating the public and clinicians about recognition, diagnosis, and effective treatments of MDD and its variants; increasing the mental health workforce; and providing better mental health care coverage.

Diagnostic reliability has been a problem since DSM-I and remains so through DSM-5-TR. MDD is a heterogeneous construct that limits communication, prognostic accuracy, and drug development, and it may be a key reason none of the current treatments are effective for more than about one-third of those receiving MDD diagnoses. There are 227 possible combinations of symptoms that can meet DSM-5 criteria for MDD, and 2 different patients with no overlapping symptoms can receive MDD diagnoses.

Attempts to subtype MDD by clinical features (ie, anxious, mixed, atypical, catatonic, melancholic, psychotic), onset (ie, first episode, recurrent, childhood, seasonal, premenstrual, peripartum, menopausal, late life), trigger (ie, autonomous or after life adversity), state (ie, prodrome, episode, response, remission, recovery, treatment resistant, difficult to treat), comorbidity (ie, substance use, posttraumatic stress disorder, obsessive-compulsive disorder, generalized anxiety disorder, eating disorders, borderline personality disorder, pain, chronic and disabling general medical and neurological conditions), and other associated features (ie, early life adversity, suicidality, neurocognition, isolation, poverty, cultural diversity) by and large have not identified specific treatment targets.

Other questions remain. For example, why does a diagnosis take 2 weeks? It may not make sense to wait 2 weeks when an individual has a history of severe, life-threatening episodes and a very recent onset of anhedonia, feelings of worthlessness, and suicidal thoughts. On the other hand, it may be wise to wait more than 2 weeks for first onset with mild symptoms ostensibly triggered by overwhelming interpersonal, health, or environmental stress. And why not include such common and disruptive symptoms as physical or psychic pain, anxiety, cognitive problems, irritability, or rumination?

The diagnosis of MDD does not yet map very well with underlying biology or treatment outcomes. The National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) was an attempt to improve upon our current symptom-based diagnostic system, but it has not been widely accepted or implemented. There are no easy solutions, but the quest to find a more reliable diagnosis for this all-important condition must continue.

 Two additional diagnostic issues of import in contemporary psychiatry are the relationships of MDD to burnout and bereavement. About 40% of health care workers experience distressing symptoms of burnout, likely even more so since the start of the COVID-19 pandemic. In working in the physician wellness arena, I see many physicians complaining of burnout. Some come to me on previously prescribed antidepressant medications, which have essentially no positive effect on burnout. Others present with significant underlying MDD that has been misattributed to burnout.

This diagnostic confusion is at least in part explained by overlapping clinical features, such as unhappiness, low energy, poor sleep, and a defeatist attitude. But burnout is predominantly a job-related condition, the core feature of which is mental and emotional exhaustion related to ongoing work stress. MDD, on the other hand, is a persistent, pervasive, and pathological mental condition, the core features of which are unhappiness and the inability to find joy in anything. In burnout, self-esteem is preserved, whereas feelings of low self-worth and even worthlessness often predominate one’s self-view in MDD. In contrast to the experiences of those with MDD, individuals with burnout often retain the capacity to laugh, to appreciate the comfort and support of relatives and neighbors, to be consoled, and to recognize that what they are going through will lessen in time. The importance of differentiating burnout from depression may not be primarily an either/or proposition —wondering whether something is burnout or MDD—but one of identifying when an individual who presents with features and symptoms of burnout may also have MDD. Failure to do so risks the potential of missing the detection and opportunity to provide effective treatment for individuals suffering a serious, if not life-threatening, mental disorder.

The DSM relationship between bereavement and MDD has had a somewhat convoluted history. In a well-intentioned effort to avoid medicalizing ordinary grief and the subsequent overprescription of antidepressants, DSM-III introduced the “bereavement exclusion,” which cautioned against diagnosing MDD after the death of a loved one. Subsequent research suggested that major depressive syndromes following bereavement did not meaningfully differ in nature, course, or outcome from depression of equal severity in any other context, or from MDD appearing out of the blue. Disqualifying a patient from a diagnosis of MDD simply because the clinical picture emerged after the death of a loved one risks closing the door on potentially life-preserving interventions.

DSM-5 provides useful guidance on when to diagnose MDD in the postbereavement period. For example, in bereavement-related grief not accompanied by MDD, loss and preoccupation with the deceased person are predominant themes and self-esteem is usually preserved. In contrast, in MDD, persistent and pervasive unhappiness and the inability to enjoy anything are predominant themes, and feelings of worthlessness and self-loathing are common. In ordinary grief, waves of emotional pain are usually accompanied by positive emotions and fond recollections of the deceased. In MDD, pervasive misery and unhappiness are the norm. Despite these differential diagnostic guidelines, DSM-5 does not compel the diagnoses of MDD after bereavement but instead allows for clinical judgment by retaining the V code “uncomplicated bereavement.”

DSM-5-TR has added a new diagnosis, prolonged grief disorder (PGD), which is sometimes misdiagnosed as MDD or masked in someone who also has MDD. The DSM-5-TR criteria for PGD require that distressing symptoms of grief continue for at least 12 months following the death of someone close. The grief response is characterized by intense longing/yearning for the deceased person and/or preoccupation with thoughts and memories of the lost person to a clinically significant (ie, impairing) degree, nearly every day for at least the past month, along with at least 3 of the following 8 symptoms: (1) feeling as though part of oneself has died, (2) a marked sense of disbelief about the death, (3) avoidance of reminders that the person has died (often coupled with intense searching for things reminiscent of the deceased person and/or evidence that they are still alive, such as mistaking others for the person who died), (4) intense emotional pain (anger, bitterness, sorrow) related to the death, (5) difficulty with reintegration into life after the death, (6) emotional numbness (particularly regarding an emotional connection to others), (7) feeling that life is meaningless as a result of the death, and (8) intense loneliness as a result of the death. The burden of these symptoms causes clinically significant distress or impairment, and the duration and severity of the bereavement reaction clearly exceeds social, cultural, or religious norms for the individual’s culture and context.

PGD is a serious mental disorder that puts the patient at risk for intense distress, poor physical health, and shortened life expectancy. PGD can be differentiated from MDD in a similar manner to differentiating ordinary grief from MDD. In PGD, the dysphoria is more tied to yearning, pining, and preoccupied thoughts and memories of a loved one who has died rather than the more persistent, pervasive, all-encompassing misery of MDD. PGD can also be successfully treated, as shown in a series of randomized clinical trials comparing a 16-session PGD-targeted therapy versus treatments efficacious for major depression.

 Indeed, many patients in those trials had been aggressively treated for MDD for years before enrolling. Thus, clinicians who learn to accurately assess PGD and to offer or refer individuals for appropriate, targeted treatment can spare their patients years of suffering.

 Despite many clinicians’ best efforts to select the antidepressant medication most likely to benefit their patient, many patients cannot tolerate a high enough dose to optimize benefits; of those who can, only about half to two-thirds respond and only about one-third achieve remission. Even among those who remit, relapse and recurrence are the norms, often within weeks to months after remission and many more times over the life span. At least one-third are considered to have treatment-resistant depression (TRD). Individuals with TRD have a much more debilitating form of illness than those with MDD, including increased mortality from suicide as well as all-causes mortality.

 Yet clinicians do not yet have solid, evidence-based, optimal pharmacologic choices for either first-step or next-step treatments. Given the prevalence of MDD and its associated morbidity and mortality, the search for optimal first-line and next-step treatments should be a national priority.

The concept of TRD, based solely upon failure to achieve remission with 2 or more adequately delivered medication trials, may have outlived its usefulness. A broader, perhaps more empathic, concept of difficult-to-treat depression (DTD) has been proposed to replace TRD.

 DTD is defined as “depression that continues to cause significant burden despite usual treatment efforts.” It considers not only symptomatic remission and response but also treatment intolerance, “poop-out,” relapse, recurrence, functioning, and quality of life.

In the DTD model, treatment combines optimization of symptom control, maximizing function and minimizing treatment burden where remission cannot be obtained.

 Although TRD may be seen to suggest a defeatist attitude to treatment, DTD is a more open concept that incorporates lifelong management and fosters a collaborative approach between the physician, patient, family members, and other providers to overcome difficulties and challenges. A patient-centered approach to lifelong disease management, based on shared decision-making around all aspects of treatment, is recommended.

6. The role of “out-of-the-box” interventional therapeutics.

 When I was training as a psychiatrist more than 50 years ago, we had tricyclic and monoamine oxidase inhibitor antidepressants, and we began the search for medications that were better tolerated, worked more quickly, were more effective for a broader range of patients, and had more sustainable effects. Several new medications and classes of antidepressants have been developed in the ensuing decades, but until very recently the search was focused exclusively on monoaminergic-based strategies.

More recently, the discovery of ketamine’s rapidly acting, profound antidepressant and antisuicidal effects has spurred great interest in finding other, nonmonoaminergic, “out of the box” treatments. Intranasal esketamine was the first of these to be approved, initially as an adjunctive treatment for TRD and more recently for depressive symptoms in adults with MDD and suicidal thoughts and behaviors. At the same time, we are seeing a resurgence of interest in psychedelic therapies. Several studies have suggested safety and rapidly acting effectiveness of psilocybin therapy for MDD and TRD, and more large, multisite randomized controlled trials are coming.

 Many unanswered questions about psychedelic therapy remain, involving ideal dosing; what forms of psychotherapy might best augment the drug’s effectiveness; how to best sustain effects and deal with relapse, recurrence, and long-term maintenance; and how to make these labor-intensive treatments feasible in outpatient treatment settings.

One of the most exciting aspects of psychedelic therapies is the marriage of pharmacotherapy and psychotherapy inherent in these interventions. This may present an aspirational model for all interventions and an important component of future training. Although great enthusiasm greets the promise of psychedelic therapies, we also are seeing increased interest and improvements in other nonpharmacologic treatments, such as repetitive transcranial magnetic stimulation.

 Thus, our tools for treating MDD are finally and rapidly extending beyond monoaminergic pharmaceuticals and a few evidence-based psychotherapies to new, innovative, and potentially game-changing interventions.

An abundance of literature documents the superiority of antidepressant medication plus psychotherapy over medication alone for MDD. Yet when it comes to training the next generation of psychiatrists, we are observing a monumental paradox. Since 2013, the Accreditation Council for Graduate Medical Education (ACGME) standards and requirements for psychotherapy training in psychiatric residencies call for developing competencies in the areas of cognitive behavioral therapy, psychodynamic psychotherapy, and supportive psychotherapy in both brief and long-term formats, with optional experiences in group and couples/family therapy. However, fewer psychiatrists than ever are providing psychotherapy to patients with MDD, or any diagnoses for that matter.

 Fifty percent of psychiatrists do no psychotherapy, and only 10% regularly provide psychotherapy along with medications.

 This current state and evolving trend is unacceptable. The ACGME requirements have not served their purpose,

 and future training may benefit from fewer top-down mandates and more trust in training programs to implement their own standards and innovations.

8. Physician burnout, depression, and suicide. 

Physician distress is increasingly recognized as a professional and public health crisis. High rates of suffering including career dissatisfaction, secondary trauma or second victim phenomena (in psychiatry, often related to coping with patient suicide), burnout, substance abuse, depression, and suicide are all receiving national attention and calls for action.

 Although there has been outpouring of attention to recognize and attenuate physician burnout, far less attention has been allocated to the recognition and treatment of MDD in physicians. Yet, perhaps the most actionable prevention strategy for suicide is prompt recognition in optimal treatment of MDD.

Physicians have rates of MDD similar to the rest of the population but are no more likely—perhaps less so—to access treatment. This is due, in part, to continued stigma related to mental illness, but also to fears regarding the consequences of diagnosis and treatment on standing in the professional community and licensing, promotion, and insurance concerns. No doubt, avoidance of treatment relates to the high suicide rates noted in physicians. Distinguishing features of physician suicide include: female physicians die by suicide more often than females in the general population; suicide is the leading cause of death among male residents and the second-leading cause of death among female residents; physicians are more likely to have a job problem (hence, attention to improving well-being and reducing burnout cannot be overestimated); a higher proportion of physician and nurse suicide deaths are by overdose compared with the general population; depression is as significant a risk factor as among nonphysician suicide deaths; and physicians who took their lives were no more likely to be receiving mental health treatment compared with nonphysicians who took their lives.

Preventing physician suicide requires evidence-based actions that multiple stakeholder groups can take, including regulatory agencies, licensing boards, and hospital privileging boards; specialty boards, professional associations, and continuing education organizations; medical educators; and individual clinicians.

 The key is that each of these constituencies prioritizes the well-being and mental health of the health care workforce—not just physicians, but the entire teams physicians work with—so they can live fully and practice their profession at the top of their game.

The very recently passed Dr. Lorna Breen Health Care Provider Protection Act, which requires the US Department of Health & Human Services (HHS) to take actions to improve mental and behavioral health and prevent burnout among health care providers, is a major step forward. Several national initiatives to address the issues of physician well-being, burnout, and suicide have emerged. What these programs have in common is attention to evidence-based practices, safe and accessible avenues for physicians to address mental health concerns, confidential and timely follow-up, and stigma reduction.

 At UC San Diego, the Healer Education Assessment and Referral (HEAR) Program offers a comprehensive educational program, proactive screening and warm referrals, crisis intervention and critical incident debriefing, ongoing confidential counseling/therapy for house staff, group support, peer supporter training, and interdisciplinary Schwartz Center Rounds.

 Each aspect of this comprehensive program is readily transportable to other institutions.

In summary, although there has been an explosion of knowledge in the neuroscientific basis of mental disorders, genomics, neuroimaging, and neuropsychology, there remains considerable room for growth in how we provide equitable access to evidence-based treatments; define and diagnose MDD; create evidence-informed first-step and next-step, personalized treatment decisions; conceptualize TRD and consider replacing or supplementing it with DTD; develop novel interventions that provide options for better tolerated, more effective, more sustainable treatments; more effectively train future clinicians to competently employ a broader spectrum of evidence-based treatments than the current norm; and shift the culture of medicine to one that prioritizes optimizing our own wellness and mental health.

No doubt readers will have their own ideas of what deserves to be in a top 8 list and may have different perspectives on my somewhat subjective views. We would love to hear from you!

 is a Distinguished Professor of psychiatry at the University of California, San Diego.

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How many different ways do patients meet the diagnostic criteria for major depressive disorder?

The clinical characterization of the adult patient with depression aimed at personalization of management

A key differential diagnosis for physicians—major depression or burnout?

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Optimizing treatment of complicated grief: a randomized clinical trial

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Prolonged grief disorder diagnostic criteria—helping those with maladaptive grief responses

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Clinical research challenges posed by difficult-to-treat depression

The therapeutic potential of psilocybin: a systematic review

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Preventing clinician suicide: a call to action during the COVID-19 pandemic and beyond

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Update on the UC San Diego Healer Education Assessment and Referral (HEAR) program

What are the biggest challenges facing both clinicians and patients, and how can we address them?

8 Key Issues in the World of Major Depressive Disorder

The Major Issues in Major Depressive Disorder

A psychiatrist lists the top 8 most pressing issues in MDD, from training to accessibility.

Niall (“Jock”) McLaren is an Australian psychiatrist. He is Honorary Research Fellow in the Department of Philosophy at University of Queensland. He recently retired after nearly half a century of practice, including 25 years in the far north of Australia. He has extensive experience in remote and military psychiatry and posttraumatic states. He has published extensively on the application of the philosophy of science to psychiatry, most recently with a formal integrative theory for psychiatry, the biocognitive model. He was previously interviewed as part of this series in 

 Since your participation in this series in 2019, you have written and published your new book 

Natural Dualism and Mental Disorder: The Biocognitive Model for Psychiatry

 I am excited to have you back in the series to discuss the details of your model. Our earlier exchange gives the readers a fair idea of your discontents with contemporary psychiatry. Let’s begin with the notion of “natural dualism.” What do you mean by that, and how does it differ from the more commonplace notion of “dualism” that many mental health professionals are familiar with?

 Thank you, and that is an important question to start with. Talking philosophy to a psychiatric audience is never easy, as too many psychiatrists seem to think that they are biological scientists, so it does not apply to their activities—but it does. 

 is simply the process of confronting and trying to answer complex questions, and what is more complex than the nature of mind and its disorders? Dualism is one attempt at answering the question of the nature of mind, but it gets a bad press these days, mainly due to misunderstanding. Dualism means 2-fold—that mind and body are not obviously the same. Richard Watson said, “The crux of dualism is an apparently unbridgeable gap between 2 incommensurable orders of being that must be reconciled if we (wish to justify)  our assumption that there is a comprehensible universe…”

 That is neat, because it also tells us there are 2 forms of causation.

Historically, dualism relates to the French polymath, Rene Descartes (1596-1650), who said mind and body are composed of 2 different substances: the physical stuff of bodies and brains, and the mental stuff of the mind, each requiring nothing other than itself to exist. That leads to the problem of how those substances can possibly interact—the classic 

, of which he was perfectly well aware. It also leads people these days to deride his work. For example, philosopher Daniel Dennett of Tufts University in Boston dismisses with contempt any idea of dualism as pure magical thinking. Instead, they try to eliminate 1 side of the question by building a nondualist or monist philosophy of mind, such as “Mind and brain are a unity” or “Mind reduces to the brain.” That does not work, and never will work.

Natural dualism says “Yes, mind and body are profoundly different, with no properties in common, but mind arises from the brain by natural, law-like processes (laws of supervenience),” which we can probably understand. The idea is closely associated with philosopher David Chalmers, but very explicitly, there is no magic involved. My work takes it further and offers a biological mechanism by which a nonphysical mind supervenes upon or emerges from the physical brain. I have suggested what those laws are, but crucially, it uses processes that we have known about for a long time.

 You present a computational model of the mind as an informational space. What do you see as the boundaries of your notion of the “mind” here? When it comes to psychological processes such as memory and perception, which possess an essential neurobiological dimension, where does 

This can be confusing because we are sentient beings; our entire perception of ourselves is based in this point. We are first and foremost information detectors, collectors, processors, storers, and transmitters. In the book, I derive a formal definition of information, but essentially, it is what we know and experience—what we can act on and communicate. That is the result of the brain doing its job as a very high-speed, multichannel information processor of ineffable complexity. The main boundary of the mind is that it is utterly private. My brain generates my mind, and you cannot share it unless I use speech or action to convey a small part of it. The next boundary is that the sense of mind or consciousness the brain generates is completely dependent on the healthy brain. Even slight variations in physiology, such as a fever, can interfere with the natural process of generating the mind. We call that confusion or delirium. Physicians have to be very aware of it.

Descartes said that if you want to know the mind, the only place to start was in the dissecting room, and I totally agree. It is not possible to understand the concept of a mind emerging from the brain without a detailed knowledge of the brain and neurophysiological processes. This means, of course, that if the biocognitive model gets any traction, then the field of a nonmedical psychology will shrink dramatically. But it also means that the concept of a reductionist biological psychiatry is headed for the history books, replaced by a well-grounded mentalist psychiatry.

 within this framework? How does your view of personality differ from how personality is conceptualized in psychodynamic terms, or how it is conceptualized by the 5-factor model proponents?

I spend quite a lot of time deriving a formal definition of personality, which doubles as a description. Because this is a computational model, not hydraulic as the Freudian model was or static as in DSM terms, personality devolves to the particular set of rules which determines each of us as a unique human being. Remember that this set of rules is vast, and we often do not know what they are, but I explain all of this. Personality must be seen as a very dynamic process, not a fixed thing. What we call a normal personality results from a set of rules which are both internally consistent and consistent with the rules of the larger society, producing a cheerful (euthymic) person who meshes with the surroundings. However, if my rules are internally contradictory, producing distress or confusion, or clash with the larger society’s rules, producing conflict (or both), then we have personality disorder. Of course, my rules can change, for better or for worse. That means personalities can change; they are not genetically fixed. This may be abrupt as in posttraumatic cases, or gradual as in education and life experience. But the biocognitive model allots a much greater role to personality in mental disorder than biological psychiatry does. Biological psychiatry wants to see everything as “chemical imbalances.” No, it is not.

 How are “mental disorders” defined in the biocognitive model? How does your notion of mental disorder differ from, say, how the DSM understands mental disorders (a syndrome that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning that leads to significant distress or 

First point to mention: Mental disorder is real. It is as real as hunger or the pain of appendicitis, so the so-called “

” approach—that mental disorder is a myth—is completely wrong. Second: DSM is avowedly atheoretical. It is a nosology, not a model of mental disorder, although it implicitly supports the reductionist approach. It is descriptive, not explanatory, so, except in the case of posttraumatic disorders, it does not assign causes. DSM-5 gives only 3 pages to discussing “psychological factors affecting medical conditions” in the vaguest terms possible.

In a few words, the biocognitive model says that mental disorder is a state of self-sustaining mental distress and dysfunction. Mental disorder is not like ordinary grief, which resolves itself, or a bit of a fear that people can work on, or being angry over your team losing, because we get over that sort of thing. That is our nature. The mere presence of distress or poor performance does not 

 constitute a mental illness—it only becomes mental disorder when it is self-sustaining and the person cannot recover.

The model assigns a major role to personality, to current stressors and to cultural factors, but more importantly, it offers a formal mechanism of integrating psychological (including personality) and sociocultural factors into the clinical picture. DSM does not do that; it does not offer a model of mind or any integrative mechanisms. For all those people who have wanted a genuinely integrative “biopsychosocial model,” here it is.

 In your model, how does the process become self-sustaining? Are there analogous ways in which information processing in a computer can be self-sustaining? Another prominent approach in psychiatry that emphasizes the self-sustaining nature of mental disorders is the network theory,

 which conceptualizes mental disorders as symptom networks where symptoms are causally related to each other (instead of being caused by a latent variable or a central disease process), and “If these causal relations are sufficiently strong, symptoms can generate a level of feedback that renders them self-sustaining.”

 It seems like there are different ways in which it is possible for us to theorize how psychiatric syndromes become self-sustaining.

 The process of mental disturbance becomes self-sustaining by a simple feedback loop more or less consistent with what Norbert Wiener described in 1948, the difference here being that part of the loop is cognitive—a matter of what the subject knows and believes. The arrow of causation loops between mental and physical. I have given a number of examples of how seeing or hearing something can generate an unpleasant mental state whose symptoms then cause the person to become more distressed. It is a simple matter; we see it myriad times a day in anticipatory anxiety, but it also applies to normal life.

For example, “Mr Smith” has to give a talk in front of his bosses. He is worried about how he will perform, and his heart starts to beat a bit faster. But he believes a fast pulse means an impending heart attack, so, as soon as he becomes aware of it, he becomes more agitated, which makes it beat faster. Before long, he is so agitated he has to cancel his presentation. That is an easy one—extremely common, for which beta blockers are rapidly effective, and cheap. But the crucial factor is the cognitive element—that the patient must be scared of his own symptoms. I have also emphasised the Challenge Hypothesis and its role in dominance hierarchies, and how the drive to dominance produces its own instability. This is important, not just in psychiatry, but in social and political life.

Network theory, on the other hand, seems to be deficient in that it does not involve this crucial cognitive factor. The concept uses the recursive properties of networks, but inserts symptoms as the nodes, not giving credit to the notion that symptoms do not exist in isolation—that they exist separate from the mind. They are part of a much larger mental state of which the subject’s knowledge state is an integral part. Because network theory is not part of a larger theory of mind, it treats the human as an automaton, not a sentient being. I am not much convinced by these highly abstract theories in cognitive sciences. It always seems to me the theory comes first, then they look for somewhere to apply it.

 Does your definition of mental disorder exclude any conditions presently classified as mental disorders? For example, would “prolonged grief” count as a mental disorder under your framework?

I do not believe in “psychiatry unlimited.” The biocognitive model excludes a lot of what has become “disease” over the past 40 years since DSM-III burst on the scene. Just as 

 is the normal reaction to the perception of a threat, grief is the normal reaction to the perception of a loss—any significant loss. It is the converse of attachment—the downside to our capacity to form relationships—that defines us as humans. For a grief reaction to resolve, the sufferer must be able to build a new and satisfying lifestyle. All that takes time, a supportive environment, opportunities, and so on. Grief only becomes a disorder when it cannot get better or is life-endangering. If it does not get better, it is the psychiatrist’s job to work out why, and to help the sufferer work through the loss to build a different future—not to throw suppressive drugs around. Same goes for childhood disorders such as “attention-deficit/hyperactivity disorder.” The biocognitive model says, “Every child is different, so the learning environment must be tailored to the child, not vice versa.”

At present, psychiatry locates the disorder in the individual. That is what biology and genomics looks for, but that is an ideological stance. It has no argued basis in science. I will give a reference for that: In the interactive model, some disorders are inherent in the individual, some are wholly reactions to social events, but the great majority are a complex mix of biological, psychological, and social factors. Sorting that out brings back the art of psychiatry.

 Psychiatric conditions often entail prominent bodily manifestations, such as psychomotor retardation, appetite changes, sleep changes, blunting of affect… how do you conceptualize these physical manifestations of psychiatric disorders in informational terms?

Everything we do is mediated by informational flows. I move my index finger: Instructions have been sent as information in neurons via pyramidal tracts to AHC to motor end plate; prior to that, the decision to move it was affected by information processing in the cerebrum, but our technology is not quite up to that task yet. I explain all of this in general terms showing how the mind-body problem can be resolved quite easily using available technology. I give an explanation for blunting of affect in depression and put a lot of emphasis on the role of anxiety in mediating many of the changes we see in mental disorder.

I think anxiety is very important—in fact, I wrote a 

 about it—but that is swimming against the DSM tide, because DSM wants to see discrete categories of mental disorder, whereas I am arguing that it is all dimensional. The biocognitive model is much more complicated than the DSM “tick a box” approach. And quite often that complexity requires judgement and discretion; psychiatrists actually have to work hard to understand what is going on. But anyway, I give precisely defined examples of how somatic changes are enacted. This is not rocket science, but it does require a different mindset. I have to say this: The worst effect of the modern “biological” push in psychiatry is that it made psychiatry boring.

 If mental disorders are purely a matter of informational malfunction, how does your model account for the presence of neurobiological risk factors (such as genetics, HPA axis, inflammation, neurotrophic factors) that influence the probability of experiencing various mental disorders? Similarly, if the mind is purely informational, how do 

 and biological interventions successfully change the informational content?

 Mental disorder is the overt or experienced manifestation of some disturbance in the brain-mind complex. Remember that when something goes wrong in an informational model, there are 2 aspects to consider: (1) the physical, meaning the brain, and (2) the informational or mental. The initial physical state of the brain is determined by the genome; the most extensive studies so far have failed to find any significant genetic contribution to any single mental disorder. At best, there is a generic tendency to mental disorder which, as I argued in the 

 is probably a genetic tendency to overreact to perceived threats. But we know from the Challenge Hypothesis that people who feel threatened will perceive more threats, which has direct effects on activating a wide range of defensive systems in the body. Using the Challenge Hypothesis, I put a lot of emphasis on the role of testosterone as an inherent destabilizing factor, but people do not like it—they see it as threatening. They want to see themselves as coolly rational, but they feel threatened if you want to talk about their response to threats.

the chemicals are under direct mental control. The mental perception is the first event in a long causal chain. That is directly opposite to what reductionist biological psychiatry says and, I say, explains why they cannot find any primary physical causes to mental disorder. There really are not any. But until now, psychiatry has not had a model of mind tailored to its needs, so they tried to write the mind out of the equation.

 You have said that the biocognitive model offers “a genuinely bio-psycho-social model.” Can you elaborate on that? What makes this model bio-psycho-social?

 It is biological in that it says you cannot even begin to work out why the human mind is as it is without taking into account the “wetware” of the entire CNS. And the rest of the body, of course. It is psychological, as it says the mind runs the brain, not the other way around, and it shows just how the mind-body problem is to be approached so that a resolution falls into place. With a formal mentalist theory of mind, firmly grounded in the physical structure and function of the brain, we can integrate social factors into the calculation instead of paying lip service as DSM does. What you believe becomes instrumental in determining how you behave and how you feel, which solves the determinism question: Yes, we most definitely do have free will, but, as 

 and so many others indicated, it is biased.

 We are not half as rational as we think we are.

The problem is what has been called “The Great Twentieth Century Prejudice” of insisting that mentalist constructs are necessarily supernatural. This has led to so many dead-ends, biological reductionism, behaviorism, functionalism, the list goes on. We humans have mental capabilities. The problem for science is to give account to them, not write them out of the equation.

 “Primary physical causes” aside, I want to clarify something here. You emphasize the direction of causality from mind to the brain (eg, “mind runs the brain”). You also mention the importance of biology, which suggests a bidirectional causal relationship. Do you think that the mind-to-brain casual interactions are more important in the case of mental disorders than brain-to-mind interactions?

 Yes. That is the whole thrust of the model: to outline mechanisms by which the individual’s knowledge state triggers the emotional reactions, which are seen as “mental illness.” Anxiety, as I argued in my little monograph, is the model of a pure psychological disorder—there is no brain disease at all. The cognitive model relies on the feedback loops which I mentioned before. Remember the loop goes from mind to body and back to mind again, where the reinforcement occurs. In grief, it is the knowledge that something precious has been lost that triggers the emotional reaction, of misery, despair, hopelessness, etc. 

 starts with the awareness, even less-than-conscious, that life is hopeless and will never get better; the emotions flow from that, not the other way around. The most common cause of a recurrent or chronic depressive condition is an unrecognized anxiety state. But psychiatrists do not take anxiety seriously.

The principle here is important: Psychiatry has to acknowledge that mental states have mental causes. There is in principle no way a mental state can be reduced to a physical state of the brain—that confuses the product with the mechanism. Yes, I know that people like Eric Kandel and Richard Carrier and so many others are sure it can be—all that is lacking is a model. I would like to see one, but they have never produced it.

 Does the biocognitive model have any implications regarding how psychiatric disorders should be classified?

 It certainly does. It immediately says that the current categorical approach to mental disorder, in the form of the DSM system, will not work. That is not new; even Thomas Insel said it. The biocognitive model requires a dimensional approach, which was entertained for personality disorder in 

, but they had to abandon it. They realized that if they started using it on 1 part of mental disorder, the entire categorical approach would fall apart, and they were not prepared for that. So instead of this relentless growth of mental disorder, classifying everything that moves as “illness,” the biocognitive model offers a more restrained psychiatry that looks carefully at all aspects of the person’s life and tries to understand them in an etiological sense: “What has happened to get this person into this position in life today?” That takes a lot more art than simply ticking a few boxes in a noisy emergency department. We must resurrect the art of psychiatry and stop this pretentious nonsense of talking about “clinical neurosciences.” And it says that Insel’s project to develop a classification based in “brain circuits” will go nowhere—it is in fact an irrefutable claim, so his project is nonscientific.

 Since you do accept that taking into account the “wetware” of the CNS is essential, what sort of neuroscientific research do you think it makes more sense for psychiatric researchers to pursue?

 The first thing for any psychiatric researcher is to work out what psychiatrists should be studying, meaning they have to write their model of mental disorder. There cannot be a research program without a model of the field; that is not science. We do not need to be doing any “neuroscientific research”—we need a consensus on the nature of mental disorder and the best way of approaching it. For example, look at the vast sums of money spent on genomic research with, even its most ardent supporters would agree, skimpy results that have never influenced treatment in any way. But who proved that mental disorder has a genetic basis? Nobody—it was just assumed as an article of faith. You might not remember the “biogenic amines in the hypothalamus” story, or taraxein or minimal brain damage; the research preceded the elementary process of working out whether these things were possible. It was only when the research failed that people wondered if it ever had a chance, but by then they had moved on to the next fad.

That is what the biocognitive model is about: Here is an articulated model that starts with first principles and builds a structure that can be tested. It says, “The great bulk of ordinary mental disorder is wholly psychological with no underlying brain disorder.” It does not actually need much basic research; we can comfortably ride on other researchers’ work. But regardless, the model has to come before any research program is written, the model dictates the research program, and psychiatry has never done that.

 Critical psychologists in the United Kingdom (eg, proponents of the Power Threat Meaning Framework and DropTheDisorder movement) vehemently reject the notions of “disorder” and “dysfunction” entirely and prefer to see psychiatric conditions as “normal understandable reactions to life circumstances.” What would you say to such critics in defense of your continued use of the term “disorder”?

I have never heard of those movements, but it sounds like they are the latest version of Szasz's theme. 

, just did not get human distress. I will reference my critique of his approach. There is a clear difference between “normal understandable reactions to life circumstances,” which will get better with time and support and adjusting one’s ambitions and so on, and mental disorder which does not get better because the person has become trapped in a self-sustaining state of distress. This notion is critical. I put a lot of emphasis on this concept in the book, using different examples but mostly cases of anxiety because it is so obvious and so important.

Anxiety is the only recursive human emotion; it can act back on itself to reinforce and intensify itself. Anxiety is serious—do not believe anybody who says otherwise. It becomes the exemplar of the serious mental disorder that arises in the setting of a perfectly healthy brain. Is this possible? Of course, because there are 2 realms in the biocognitive model: the physical or brain level and the psychological or informational level. Errors can occur in either of them. In an information processor, can glitches in data input or the processing algorithms cause the machine to seize up or shake itself to bits? That is a no-brainer.

 In cognitive sciences, we have seen a shift toward what are called the 4E approaches according to which mental processes are Embodied, Embedded, Enacted, and Extended.

 4E approaches are skeptical that cognition can be described fully in terms of abstract processes such as computations and representations and argue that we must refer to bodily mechanisms and active interactions between the organism and the environment when talking about cognition. Do you see any incompatibility between your computational view of the mind and the 4E approaches?

 Oh boy. I was restricted to 70,000 words, so there are lots of topics I did not mention, and bringing in too many esoteric subjects is a great way of losing your readership. I have not read that particular book, and while there are lots of books I have not read, my impression is that my work is entirely consistent with their approach. I have always said that if a model of mind does not generate a model of mental disorder, it is not worth the paper it is printed on. The available models of mind, and I do not want to sound as though I am picking on him, but Dennett’s functionalism is a good example: It does not lead to a model of mental disorder. We can discard all those models. But the Embodied Cognition model—yes, I am 110% on the same side as they are. What did you say? “We must refer to bodily mechanisms and active interactions between the organism and the environment when talking about cognition.” Yes. Totally agree. I have just written a book about that. That means for the first time in its history, psychiatry is right up with the latest trend in philosophy.

And there is another book illustrating this point due out at the end of this year. Last year, I was feeling a bit tired of psychiatry, so I decided to apply the biocognitive model to a different field—one that interests me: politics. Specifically, I looked at the question of ultra-right-wing extremism, aka fascism. The biocognitive model gives a novel view of this crucial topic, but it is not “psychiatry unlimited” because it concludes, “These people are not mentally ill.” It is a growing field, and it all goes back to dualism. Descartes was on the right track after all. Thanks for your questions; it is an interesting field.

 I found your account of natural dualism and its application to psychiatry quite interesting, despite some reservations. I am curious to see how it will be received by philosophers of mind and philosophers of neuroscience, as these are highly contested and actively debated issues with many deep disagreements among philosophers. Aside from the intriguing discussion of natural dualism based on information processing, the notion of mental disorder and biopsychosocial integration that you end up with in the book seem to me to be fairly similar to various existing philosophical and nonreductionistic approaches. It is pretty standard to conceptualize mental disorder in terms of distress and dysfunction (the philosophical challenge that many have taken up in recent years has been to develop conceptualizations of mental disorder that do not rely on notions of dysfunction). The emphasis on self-sustaining has also become prominent in the last decade thanks to network theory but has existed in various forms previously. The dimensional nature of mental disorders also has a long history, represented these days prominently by the Hierarchical Taxonomy of Psychopathology (HiTOP) system. Biopsychosocial integrative approaches to psychopathology have also been around, eg, McHugh and Slavney’s 

 approach in the 1980s building on Meyerian and Jasperian foundations, or more recently, we have seen integrative and philosophical accounts offered by Bolton and Gillet (

The Biopsychosocial Model of Health and Disease: New Philosophical and Scientific Developments

, 2020). Bolton and Gillet also see biopsychosocial causal interactions in terms of information processing, and de Haan works with the framework of mind as embodied, embedded, and enactive. The novel thing about your book is that you arrive at your conclusions by developing a dualistic account of mind in informational terms, and the strength is that you link your model of mental disorder to a model of mind, but from my point of view, that is also a weakness. Given the lack of philosophical consensus around fundamental questions in philosophy of mind, I do not think that we have to take any particular stance on the viability of your account of dualism to successfully conceptualize psychopathology in dimensional, integrative, and nonreductionistic terms. In other words, to the extent that your vision of psychiatric practice is dimensional, integrative, and nonreductionistic, it is in alignment with existing dimensional, integrative, and nonreductionistic philosophical approaches, and the question for readers such as myself is whether your informational account of the mind is persuasive enough that we want to bet the viability of biopsychosocial integration on it. Your thoughts on this?

 I agree—there is nothing new under the sun. The difference here is that this model offers a mechanism of mind-body integration. Look at Wittgenstein: no model of mind. Chomsky: no formal model of mind. Dennett: a model of sorts, but no integrative mechanism and no suggestion of mental disorder. Sellars: no model or mechanism. Richard Carrier: avowedly reductionist, but no explanation—no model of mind. Thomas Nagel: interesting, but right at the end of 

Why the Materialist Neo-Darwinian Conception of Nature is Almost Certainly False

, he says, “However, I am certain that my own attempt to explore alternatives is far too unimaginative.”

 I am not arguing. Bolton and Gillett openly stated: “It is not straightforward to find the right metaphor for the relation between the biological, the psychological and the social” (p33).

 Why did they want a metaphor when they are supposed to be talking about a model? Because they do not have a model. They missed the central point: that merely describing biological, psychological, and sociological factors does not integrate them. I am forever telling people that description is not explanation.

I am not offering a metaphor. The biocognitive model offers a formal computational mechanism to integrate these facets of life which, after all, are just common sense. Of course, some mental disorder arises in brain disease—we have all seen that—but it does not tell us why the same syndromes can arise in the absence of brain disease. Most disorder is a mixture of psychological and social factors in a perfectly healthy brain because, just like a computer, “software” glitches can ruin everything. But the thing is, psychiatrists have got to stop kidding themselves they have a reductionist biomedical or a biopsychosocial or whatever model when, as a matter of demonstrated fact, they do not.

Does a computational approach to the mind pave the way for practicing a biopsychosocial psychiatry? 

The Biocognitive Model for Biopsychosocial Psychiatry: Niall McLaren, MBBS, FRANZCP

Traditionally, cognitive behavior therapy (CBT) has focused on alleviating symptoms of psychiatric disorders in addition to solving problems in patients’ lives. This is illustrated by CBT practitioners monitoring progress in therapy through symptom measures related to the psychiatric diagnosis (eg, Beck Depression Inventory, Beck Anxiety Inventory).

 Additionally, research studies on CBT outcomes typically use the same types of symptom measures to determine treatment effectiveness or efficacy. Since its inception, CBT has gathered a robust research literature demonstrating its ability to reduce symptoms of distress in a variety of psychiatric disorders.

 Nonetheless, it has been argued that although psychological treatments, such as CBT, have demonstrated the ability to alleviate distress, there needs to be a greater focus on enhancing overall well-being.

This argument is not new, and many fields of psychology do focus on overall well-being. The field of positive psychology was founded on the premise that it takes different types of interventions to enhance positive emotional states than to alleviate suffering.

 For example, practitioners of positive psychology may help patients identify their signature strengths and find ways to use those strengths in daily life. Patients can also learn how to enhance positive emotional states by interventions aimed at increasing their sense of gratitude. Enhancing well-being has also been incorporated into “third wave” treatments. Acceptance and commitment therapy includes values as a central component of treatment.

 Patients learn how to identify their values and live according to their values as opposed to being guided primarily by their thoughts or emotions.

Recently, CBT has shifted to include a greater emphasis on enhancing well-being. One specific form of CBT, recovery-oriented cognitive therapy, helps clients with serious mental health conditions identify and live in accordance with their values and aspirations.

 These strategies have also been adapted into traditional CBT.

Cognitive Behavior Therapy: Basics and Beyond, 3rd Edition

, a CBT text used by many training programs, includes an emphasis on values and aspirations, as well as a strengths-based method for CBT conceptualization. The following case example demonstrates how I incorporated strategies to enhance well-being throughout a course of CBT.

“Henry” is a recently retired high school teacher who was referred to treatment by his primary care physician due to complaints about elevated anxiety and an overall depressed mood. Henry grew up in a household with a physician father who was dedicated to his job and rarely home as a result. Both of his parents stressed the importance of learning and hard work. For instance, as a child, Henry was not allowed to watch television, as this was considered “being lazy.” His parents also criticized him for not performing at the top of his class, a result of his undiagnosed attention-deficit/hyperactivity disorder (ADHD). Henry tried to please his parents and avoid criticism by dedicating more time to schoolwork than his peers, which also led him to neglect his social life.

Henry reported fairly consistent anxiety throughout his life, mainly related to his academic and then to his work performance, as well as to how other people view him. He noted 1 prior untreated episode of depression, which occurred when he was graduating from college and was not accepted into any of the graduate school programs to which he applied. He originally planned on becoming a professor but decided on a career as a high school teacher, as he did not believe he would ever be able to get into an adequate graduate program. His second major depressive episode began about 3 months after he retired. Since becoming depressed, Henry became more withdrawn, spending most of his time on the couch watching news programs. The focus of his worry was whether he would be able to enjoy retirement and what the rest of his life would involve. Henry met diagnostic criteria for major depressive disorder, recurrent, moderate, and generalized anxiety disorder.

An important component in beginning CBT is goal setting. Traditionally, treatment goals focus on resolving problems in life and symptom reduction or management. When I asked Henry what he wanted to accomplish in therapy, Henry initially listed his goals as being: “Get out of this depression,” “stop worrying so much,” and “enjoy retirement.” Goal setting with clients should involve choosing specific goals that have measurable outcomes. Accordingly, I asked Henry what he would be doing differently—or how his life would be different—if he were not depressed, if he stopped worrying, and if he was enjoying retirement. Henry was able to come up with the more specific behavioral goals of: “Go on daily walks,” “read for fun,” and “complete more woodworking projects.”

Instead of stopping at standard CBT goals, I decided to determine if we could set additional goals to enhance Henry’s overall sense of well-being. We accomplished this by first assessing his values. I read through different potential values and asked him to rate on a scale of 0 to 10 (0 = no value at all; 10 = the most something can be valued) how important each value was to him. The areas of value we covered were work/career; learning; volunteering; intimacy; friendship; family; recreation; and health. I then asked Henry to look at his rated values and see if there was any discrepancy between what he valued and how he was currently living his life. We were then able to develop additional values-based treatment goals of: “developing and maintaining better friendships,” “developing joint interests/hobbies with my wife,” and “finding ways to contribute to society in retirement.”

Standard CBT treatment for a withdrawn, depressed patient begins with behavioral activation. Behavioral activation is aimed at helping depressed patients become more active and engaged in life by scheduling specific activities throughout the week. These activities allow the patient to have pleasurable experiences and to cut down on time spent ruminating. Traditionally, CBT practitioners help patients identify activities that give them either a sense of pleasure or a sense of accomplishment. For instance, watching a movie might be pleasurable, while exercising can lead to a sense of accomplishment.

To have a greater focus on enhancing well-being instead of solely alleviating depression, we used values-based activities for behavioral activation. Henry decided to schedule a daily walk with his wife, which was consistent with his values of connecting with his wife and helping her reach her health goals, as well as his own desire to live a healthier life. In line with his value of learning, he also signed up for a weekly woodworking class. Between classes, he decided to dedicate 2 days per week to using the skills he learned on his own woodworking projects, which was related to his work/career value of being productive. Lastly, Henry wanted to enhance the friendships he had neglected for most of his career due to taking on an excess of work tasks. He was able to focus on his value of friendship by contacting a few existing friends; he set up a weekly lunch date with a friend and joined another friend’s cycling group. 

After focusing on these activities for about 1 month, Henry’s major depressive episode resolved, but he still reported lacking an enhanced sense of well-being. We determined a few factors were getting in the way of his sense of well-being. The first factor was his deeply entrenched drive to be productive that he learned from his parents. Initially, I used the standard CBT strategy of cognitive restructuring through Socratic questioning to try to help him determine that his current activities could be viewed as being productive. For instance, going on walks with his wife was productive for his own health and for enhancing his connection with his wife. Despite this, he still held onto the idea that productivity was work-related and kept going back to the fact that his father dedicated his life to his work and chose not to retire. Instead of trying to help Henry change his view on work, I defined 

 as an important value of his. We then problem-solved how to include productivity in his life, and Henry came to the solution of volunteering as a tutor 2 days per week. By volunteering, Henry was able to satisfy his treatment goal of finding ways to contribute to society in retirement.

The second factor interfering with Henry’s sense of well-being was worry. He reported that his current worries centered on how other people viewed him and whether he was enjoying retirement as much as he should. We started worry reduction of his social fears through the standard CBT strategies of Socratic questioning for cognitive restructuring of his worry thoughts and evaluating positive (that worry is helpful) and negative (that worry is uncontrollable and potentially harmful) beliefs about worry itself. In using cognitive restructuring for his social worries, Henry was able to realize that he likely did not give as negative of an impression as he imagined, and people tended to respond positively to him when he made an effort to converse. He also came to the conclusions that he cannot know for certain what other people think of him, and he cannot control how others view him overall.

Given these conclusions, we focused on what Henry was able to control (ie, his behavior). In attempting to enhance his sense of well-being, I asked Henry how he valued acting toward others. He determined that he valued being kind, supportive, a good listener, and more outgoing. We then concretely defined what this would look like in his weekly social interactions and role-played example social interactions during sessions. He was then able to act more in accordance with his social values.

The last component we focused on was Henry’s worry that he was not enjoying retirement as much as he should. Throughout his career, Henry heard his fellow teachers discuss how amazing retirement was going to be and would hear from those who had retired how happy they were in retirement. As a result, Henry was constantly evaluating his emotional experience and thinking that he should be feeling happier in his day-to-day life. For instance, he would be completing a woodworking project, note he felt happiness at a 5/10 level, and believe he should be enjoying the project more, which would then cause his happiness to dip to a 2/10 level. Through these experiences, I helped him determine that both evaluating his sense of happiness and wanting to increase his experience of happiness tend to backfire and lead to less happiness. I also helped him come to the realization that he is not able to control his emotional state at will. I asked him to recount the last time he experienced at least a moderate amount of happiness, and whether he was focused on analyzing what was happening and how it was making him feel. He noted that he was not focused on analyzing his level of happiness at all; he was just fully engaged in the experience and even lost a sense of himself to a degree.

I guided Henry through a mindfulness exercise to strengthen his ability to notice his emotional state and related thoughts without getting caught up in them or trying to control them, while also becoming fully absorbed in the experiences around him. Henry then practiced taking this approach to his day-to-day valued experiences. He came up with the saying, “if I’m a 5 (happiness level), I can let myself be a 5.” Henry reported this intervention as being the most important in enhancing his sense of well-being, as he was able to “get out of [his] head” and experience life to the fullest.

How can a greater emphasis on valued experiences both promote well-being and alleviate stress in patients?

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