“I wanted to acknowledge the fact that I have PTSD. We don’t even know that we are suffering from this mental health disease.” This comes from an interview of musician G Herbo where he’s talking about his new album titled “PTSD”, released just last week.

‘We don’t even know’, why we feel the way we do and have the thoughts we have. Life is enormously complex, and there’s a constant inflow of stuff that our bodies process, respond to, and in turn incorporate into who we are, be it the food we eat, the air we breathe, sights we see, social interactions we have, or the countless other things we’re exposed to in our environment. Most of these things we aren’t even aware of. We’re even less appreciative of how these things are shaping who we are.

My working definition of ‘mental health’ is the health of the apparatus that manages the way we think and feel, and ultimately the way we behave. We know it is in large part comprised of the brain – but not completely. The brain’s interactions, the chemical, electrical, and physical communication with all of our other systems, have to be considered as part of that apparatus as well. Those other systems are required in many cases to receive, process and incorporate that ‘inflow of stuff’. Every piece is ‘physical’. Mental health is physical health.

Our mental health, like every other aspect of our health, is a product of our genetically determined make-up, and our experiences – all the stuff that we’re exposed to as we live life. Of course, our behavior has a lot to do with determining those experiences, but the converse is true as well, our experiences shape our behavior. The big lie we’ve accepted culturally, and that we hold ourselves to personally, is that we are, or should be aware of how these experiences inform our decision making and our behavior.

It is encouraging that the topics of mental health and mental health care are receiving increased attention in the public dialogue. It concerns me though, that much of that discourse is not in the right context, that we’re not focused on the real problems we need to solve.

It’s most often a public safety issue that puts the topic of mental health into the headlines. The most common driver of these headlines is an act of mass violence. When this happens, invariably I hear in somThe essence of this story is captured by Patrisse Cullors’ slogan “You can’t get well in a cell.” Cullors has a brother who’s been diagnosed with schizoaffective disorder and has spent significant time in the LA Jail system. She asks, recalling the first time she saw her brother incarcerated there “… why would our society allow for someone who’s sick to be treated this way, to not be given the kind of care they deserve?”

Tim Belavich, director of mental health for the Los Angeles County jail system, underscores this sentiment. “By default, we have become the largest treatment facility in the country. And we’re a jail. I would say a jail facility is not the appropriate place to treat someone’s mental illness.”

This problem is not unique to the LA jail system. Across the country, the rate of Serious Mental Illness (SMI) in federal, state and local prisons and jails is about 15%-20%. The rate of SMI in the general population is about 4%.

I am happy to say that right here in Huntsville, Alabama, our city and county law enforcement agencies are working together with Wellstone Behavioral Health, our local mental health care provider, to address this very issue. They’ve recently implemented a jail diversion program to ensure that those who need mental health care are getting that care in a timely manner. They are also providing Crisis Intervention Team (CIT) training to select officers to support their efforts to better identify and respond when a citizen they interact with has mental health issues. Admittedly, their efforts are primarily in the interest of public safety to reduce recidivism, but to me, this approach clearly prioritizes the protective mission of law enforcement and the corrective charter of our justice system.

While the numbers plainly indicate that there is a problem associated with a disproportionate prevalence of mental illness in our prison systems, there is a critical distinction that needs to be made, one that there should be no confusion about. We’ve acknowledged that the rate of serious mental illness in the jailed population is about four times higher than that in the general population. This does suggest that individuals with mental illness may be ‘more prone’ to “criminal” activity. But this in no way indicates that mental illness makes any particular individual likely to commit acts of violence or other criminal behaviors. To suggest that mental illness is a good predictor of criminal behavior absolutely puts the conversation on mental health in the wrong context. This only serves to reinforce the already destructive impacts of stigma and can only lead to similarly destructive and regressive policies around mental health care.

Mental illness is not an infectious disease, but it will have life-changing impacts on every one of us at some point in our lives. To simply quarantine those with serious mental illness, by incarceration or institutionalization, is an ineffective approach in terms of public safety, is counterproductive in terms of public health, and most importantly – it’s just inhumane.e form, the suggestion “It’s a good thing that this is bringing more attention to mental health.” I don’t agree with this presumption.

Public safety is not public health. Clearly, public safety is essential to the health of our community, and there’s no disputing that public health and safety issues often intersect, but addressing public health issues primarily as a matter of public safety is not only doing a disservice to those in need of mental health care, it’s also almost certain to be ineffective in protecting us from people doing bad things.

I’m not suggesting that the health of our community should be prioritized over its safety. The two are front and center in the news right now with the coronavirus pandemic. We are asking individuals to self-quarantine, and in some cases enforcing a quarantine where deemed appropriate to try to contain the spread of the infection. In this situation, public health and public safety might appropriately be seen as one and the same.

A couple of weeks ago there was an encouraging story on NPR, “America’s Mental Health Crisis Hidden Behind Bars.” I think it’s encouraging insofar as it indicates that we are starting to see recognition from the powers that be in law enforcement, that incarceration is not an appropriate treatment for those who demonstrate unlawful behaviors due to a mental health issue.

I want to discuss what I’ve learned, and share some of my thoughts on what a mental health diagnosis is and what value it provides.

Diagnosis: The nature of a disease; the identification of an illness. -medicinenet.com

When I began to pen my thoughts for this post, my original intent was to begin the conversation on Posttraumatic Stress Disorder (PTSD) as I’d promised a couple of weeks ago. To get my definitions straight I went to what is often referred to as the “bible of psychiatry”: The Diagnostic and Statistical Manual of Mental Disorders. Specifically I went to the most recent version, the fifth edition, DSM-5. This is the standard reference manual for categorizing and diagnosing mental health disorders.

PTSD was first introduced in the third edition of the manual in 1980. The criteria for its diagnosis have evolved quite dramatically since that time. This isn’t terribly surprising as we should expect our understanding of the condition to have grown and in turn the ability to identify and characterize its symptoms. In fact, in the DSM-5, a new diagnostic category, “Trauma and Stressor Related Disorders” was created, and PTSD found its place there. It had previously been categorized as an “Anxiety Disorder”. The rationale for this move, as I understand it, is that PTSD also includes disruptions of other emotional states outside of the fear/anxiety spectrum. As I said it doesn’t surprise me that the diagnostic criteria have changed, but the fact that an entirely new category was created to accommodate the disorder is curious to me.

Even more peculiar to me is that the first diagnostic criterion in the DSM-5 is not a characteristic of the disorder. It is the identification of an external event that could have caused the disorder; “Exposure to actual threatened death, serious injury or sexual violence…”. I believe PTSD may be unique in the manual in this regard, i.e., the identification of a presumptive cause is a requirement for the diagnosis.

Approximately 15% of veterans of recent wars, that is those who served in the Vietnam War, the Gulf War, Iraqi Freedom or Enduring Freedom, suffer or have suffered from Posttraumatic Stress Disorder (PTSD). This observation has brought a lot of attention to the realness of this disorder. It would be easy to take this information and assume that PTSD is uniquely a combat veteran’s issue. The truth is though, an estimated 8% of Americans will suffer from PTSD at some point in their lifetime.

It was in the 1970s when the diagnosis PTSD first gained acceptance. It was the observation that a great many veterans returning from Vietnam were suffering from a condition connected to their combat experiences that demanded that a diagnosis be recognized. It was in 1980 that the condition was included in the Diagnostic and Statistical Manual for Mental Disorders. There’s been a huge amount of observational research on the effects of psychological trauma since that time. That research has certainly shed considerable light on the common behavioral symptoms and prevalence of the disorder, but the specifics of what external factors and personal characteristics result in the disorder, and how it manifests in different individuals remain elusive. The current diagnostic criteria are summarized as follows: 1) Exposure to a life-threatening event, serious injury or sexual violence. 2) Recurring memories or flashbacks. 3) Avoidance of trauma reminders. 4) Changes in mood or cognition. 5) Attention problems, easily startled or violent outbursts.

Most people don’t develop PTSD following a life-threatening or otherwise violent traumatic event. For the general population, the statistical probability of developing PTSD following trauma exposure is consistent with those figures above related to combat exposure, somewhere between 10-20%. That is a wide range, and its uncertainty reflects our limited understanding of the condition, but it clearly illustrates that PTSD is not the normative response.

So who are those, let’s just say 15%, and what makes them susceptible? How much, if any, does one’s genetic makeup influence their susceptibility? What roles do environment and experience play? Of course, these are standard questions we want to answer in order to understand any non-normative behavior, be it a disorder or an extraordinary capability such as elite athleticism or intellectual or artistic genius. In any case, the answers lie in the physiological mechanisms that drive all the behaviors that define our individuality.

It was the afternoon of February 12, 2010, at the University of Alabama in Huntsville. There was a biology department staff meeting in progress when professor Amy Bishop stood up from the meeting table, pulled out a gun, and began to shoot her colleagues. She shot six people, three fatally, before the gun malfunctioned and she was forced out of the room. I remember the day very clearly. Most of the people at that meeting were friends of mine. I had worked in some capacity in the past with everyone in that room including Amy Bishop.

The lives of each of the survivors of that horrific experience were drastically changed, their life views, their very constitutions, were forever reshaped. This may seem to be a statement of the obvious, as we can all imagine that witnessing such violence and loss of life, particularly of those close to us, would necessarily cause psychological distress that could persist and change how we think and feel. But in truth, the toll that this kind of experience can take on an individual is beyond the imagination, because how it manifests is unpredictable, extremely complex, and very particular to the individual.

One of the survivors of the UAH shooting, biology professor Dr. Joe Ng, made this very observation, that is that each of the survivors responded and coped differently with the trauma of that experience. He recognized and acknowledged that he, like everyone involved, had been undeniably changed by this event, and those changes weren’t simply explainable by psychological factors alone. It made him ask the question “…why are certain people resilient to PTSD while some are very sensitive?” As he looked into the scientific literature he discovered a growing body of research documenting incidences of physical manifestations of disease associated with Post Traumatic Stress. Many of these reports described symptoms that could be associated with immunological factors. To explore this connection, Dr. Ng collaborated with psychologist Dr. Eric Seemann to look for blood-based indicators associated with PTSD. The results of the pilot study provided compelling evidence that there is indeed a connection between the symptoms of Posttraumatic Stress Disorder and our immune system.