Upstream vs. Downstream: A mental health fable

There once was a river and one day they saw someone floating down the river.  They went to try and help and before they even got to him they noticed someone else floating down the river.   Both men were badly hurt,  very badly hurt and the people who tried to help really wanted to help.  All of a sudden they noticed another person and another person and another person.   Soon it was a stream of people.   No one knew what to do.   No one knew what happened.   After a day of this someone had an idea.   We need a hospital for these poor people.   It seemed like such a right thing and everyone seemed for it….

Everyone but one person.   He said no.   Everyone got angry and accused him of not caring but he said they were wrong.   He really did care.

Finally they asked him what he thought should happen if he was so smart.   He waited until they were quiet and he was sure they are listening and he spoke softly:

“I think we need to go upstream and see what is putting these poor people into the water….. “

We have downstream mental health system.   Maybe it is time we looked upstream.

One of the greatest inadequacies of the medical model is the idea that you can truly understand someone’s behavior by figuring out what categories to put in in, what labels to apply to it.  It is not possible to understand how someone lives apart from the context of their life.

All of us live with distress, with pain, with stress.  All of us know unhappiness.  All of us know something about deprivation and threat. For some of us at some seasons of our life there seems to be little else.  For some of us the stress of getting by, of getting from the beginning of the day to the end without catastrophe, without loss and attack is simply overwhelming.  Life for some is about what is going to go wrong next and how are you going to cope and will you make it or not.  It has been that way for me more than once.

Everybody lives with a different degree of risk.  Life is harder for some of us than for others.

We need to look upstream in human life and too often we don’t.

The next time you see someone downstream,  broken,  in pain and misery consider from where they come.  Perhaps some of these things were upstream for them.

1.  Past experience.  Aversive childhood events (ACE’s) have a profound influence on the context of our lives.  Studies of people who face many problems in their lives often show a history of ACE’s.  Where you have been affects where you are.

2. Poverty.  Being poor affects your experience of life as much as any single thing I believe.

3. Housing.  Lack of safe, affordable housing affects your sense of what life is about, who you are and what you can expect from other people.  Aside from the day to day overwhelming stress of lack of good enough housing it tells you a lot about how much you matter and how threatening daily life can be.

4.  Food.  People dont do well in life who dont have enough to eat and who dont have enough healthy food to eat that they can afford to eat.  If eating enough, eating often enough, or what you can afford to eat are part of the daily stress of living then it is likely that the daily stress of living is overwhelming to you.

5. Health.  Do you have a real opportunity to be healthy?  Many of the above items relate to your opportunity to be healthy, but in this case I mean do you have the opportunity to get adequate and effective health care?  People who cant get preventive care, people for whom little deals become big deals, people who cant get care for serious conditions often face growing problems.  People who suffer,  who with a fair access to help would not necessarily suffer, live often with a overwhelming degree of daily stress.  They know what it means to hang on.

6. Jobs.  Do you have a job that enables you to get what you need to lead anywhere close to the life you want?  Do you have to work 2 or 3 jobs to make ends meet? As one person told me:  “I am forever a window shopper at the store of life.”

7.  Danger.  How much do you live with daily danger?  Every community has its own dangers.  How much does your experience of daily danger define the context of your life?

8. Race.  It shouldnt make a difference.  It does.

9. Past experience with help.  When you have tried to get help in the past do you find you could access help that mattered? Did “help” make things worse.  Was the system more a source of threat or a source of opportunity to make life better?

10. Social support.  People do better when they have a source of meaningful and trusted connection with others.  Do they have a sense of in someway mattering or is their daily experience that they are alone and dont fit in?  Life is what we do with other people and when there is not a sufficient “with” it is much more likely life will be hard.

11. Trauma.  This is also dealt with in the first item but in this instance I mean more ongoing trauma.  Are you living with ongoing injury and hurt?  Is life about attack and defense for you?

12. Relationships.  Does someone care?  Is there someone that it matters to that you care?  Are you alone?

13. Drugs.  Sometimes the things we do to medicate our misery in the end bring the most misery to life.

14. Personal strengths and weaknesses. All of us have things we are better at and worse at. We all have our burdens. We are not blank slates. Somethings feel like destiny. Others feel like challenge. What we make of what we got matters more than what we got.  I recommend you look at the research of psychologist Carol Dweck if you would like to read further on this.

All of these things and more are risk factors.   All of them can push us into raging waters.   Which ones do you fight?

There is one line of thought that says simply that people dont fall into the water.   They are propelled off it by a “mental illness” that is chronic in nature, that most of them dont know they are being propelled into the water and for the most part they will never find their way out.

Psychiatric hospitalization is basically a downstream intervention.   

Coercive interventions in general are downstream interventions.  Recovery is an upstream intervention.

 You cant help people to build a better life independent from the context of their life.  Things will still get messed up.  If you make distress, stress, pain and misery less likely to happen they tend to happen less likely.

So look upstream…

And remember….

Justice matters.

Opportunity matters.

Empowerment matters.

Learning matters.

Support matters.

And hope really matters


2 thoughts on “Upstream vs. Downstream: A mental health fable”

  1. I wholeheartedly agree with you Larry! Still, you left out THE most important ‘thing’ we all need to survive: Safe and ‘clean’ water to drink and for a multitude of other, daily tasks.

    We only need to check Flint, Michigan out to TRY to understand just how important (safe, clean) water is!

    If I am thirsty, nothing else matters. My need for water completely over-powered the pain I was experiencing from then-recent hip/femur surgery. The medical staff had removed my IV’s – but I contracted C-Diff, which was making me puke and have diarrhea – non-stop.

    I begged for water (not for pain medication), but they refused to give me any, saying I would just throw it up/shit it out within minutes. I said I didn’t care and advised them I would be compelled to “throw a temper tantrum” if they didn’t give me water – and SOON! I pointed out that it wasn’t like I was begging for “drugs” – just water!

    As it happened, I DID indeed ‘have’ to throw a temper tantrum so they would FINALLY give me some freakin’ water!

    Until this happened, I had NO idea that my need for water would totally ‘blot-out’ any other needs or desires. Not even intense, severe pain mattered (or registered) when my greatest need was water!

    A bit off-topic, you might say. I would suggest that it is the ONLY thing that will matter if our world becomes “like Flint”.

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