The Four P’s of Mental Health: People, Privilege, Purpose, and Processing

BY PETER VARNUM

A new Atlantic article teasing a book from former National Institute of Mental Health (NIMH) Director Dr Tom Insel recounts a conversation between Dr Insel and a psychiatrist from Skid Row, a neighborhood in Los Angeles known for its unhoused population and harsh living conditions. The psychiatrist talked about the “three Ps” needed for recovery: people, place, and purpose. I agree with that categorization, though in my case I would make some adjustments.

Adjustments to this framing I’d include are replacing “place” with “privilege,” which includes the point Dr Insel makes on the necessity of “place” – that someone has a safe place for recovery. Privilege enables such a place. And “privilege” is a broader, more accurate term for something the article touches on but does not state explicitly: any story about prevention, treatment, or recovery – any story about mental health – must include an accounting of how money, opportunity, or status affects the situation.

I’d also add a fourth “P,” for “Processing.” For me, and I am sure for countless others, processing my episodes of psychosis – through therapy, journaling, talks with close ones, writing and playing music, walks and hikes and jogs – has made an incalculable difference in managing my mental health. Not to mention the way I see myself and the world.

My small family has been on a worldwide excursion since December. We live in Europe, but I’m from the US and my wife is from Burkina Faso. After being away from family for two years due to Covid and with a new baby around, we planned a trip to the US for the Christmas holiday, and a trip to Burkina for January-February.

Given an episode I endured in Kenya, I was nervous for this trip. In 2010, I boarded a plane from Boston to Nairobi, took my prescribed medications and the malaria prophylactic Malarone, and spent the plane ride trying to feel the clothes of the animated Fantastic Mr Fox through the video screen in front of me. After a couple more days of no sleep, my hypomania turned into psychosis and I spent a week and a half in the psychiatric ward of Nairobi’s Avenue Hospital. I realize that Burkina Faso and Kenya are two very different places, but some of those memories have cropped up during my time here, in a way that has made me fearful, not confident.

We didn’t know that when we returned to Europe for a break between the trips, our house would be unlivable. Or that there would be a nonviolent coup d’état in Burkina the day of our flight. As a result, we have spent time in two Airbnbs while a new toilet was being installed in our home; three hotel rooms while a new president was being installed in Burkina; and family/in-law dwellings while a new sense of identity was being installed in my family. The big takeaway for me, as I write this from our settled place here in Ouagadougou, Burkina Faso is that I’m grateful for the four Ps: my people; our privilege; my sense of purpose; and the processing I’ve done in the past.

People: I know who my people are, and they show up for me.

I am so grateful to have found my partner. The details of the relationship are for us. But because we understand and support one another and how we communicate with one another, all the uncertainty we’ve gone through has been manageable. We have built a very solid and deliberate foundation together. This adventure has absolutely strengthened that foundation. I love her, I admire her, and I am unequivocally a better man next to her. She makes me believe in myself. There is nothing more powerful.

I’ve also continued my teletherapy sessions while we have traveled. My therapist, someone I have been seeing for over seven years, has followed all of this; the trust we have built up over time means that she understands and supports my choice to undertake this adventure.

And I’ve kept in touch with close friends and family, leaning on them each according to my relationship with them. This isn’t a calculated thing. It’s a feeling: I find myself needing some people in my life during a time like this. The point is that my people are here for me, I feel comfortable reaching out to them, and they give me strength.

Privilege: It is impossible to skim over the fact that we have had money and other privileges to do this.

I have written before about the privilege I come from and the chances it gave me to still succeed even when I veered from a traditional “track toward success.”

In this case, our savings have allowed us to do things like book airport hotels, last-minute flights – to the South of France, no less – and Airbnbs on very short notice. And not only that: in our previous jobs my wife and I traveled a lot, business class, meaning we built up airline and hotel status that let us skip lines, upgrade rooms, and sit at the front of Economy Comfort so we could put a bassinet up and stretch our legs during long flights. And, we both have the right to work and live in Europe through job and citizenship.

I recognize it is not right that some have a better chance at managing their mental health than others. But I can’t ignore that my privilege has been hugely significant in keeping my mental health strong during this adventure. I’m attempting to be transparent here, and I believe mental health advocacy needs more transparency on this topic.

Purpose: My life’s purpose right now is clear, and I’ve followed what’s important during this chaotic time.

My priorities are as follows: relationship with my partner and our new family, my own health, relationships with the family I was born into and my close friends, and then work. I know this because I’ve gone through the exercise of articulating these things before. And all these things are in a positive place right now. 

I do not believe I have “figured life out.” These priorities make sense for me right now, and probably they will for a long time. But how they show up today is undoubtedly different from how they’ll show up in the future, and certainly from how they showed up in the past. As I grow older, I have more questions about life; these priorities help keep me grounded as I explore the answers.

Processing: My 20 years of reflecting on my lived experience has shown me who I am.

I am grateful for this. Specifically, I am grateful that I have done the work of integrating that lived experience with how I want to live, work that will continue. As much as I wish I did not need it, I am also grateful for knowing what medication I can turn to when I do need it.

Perhaps most importantly, reflecting on my mental health has revealed who I am. This is not a person I chose to be; it is not a person I created through my own inclination. The environment in which I grew up and was educated has undoubtedly shaped me, but the real, raw, deep work I have done has gotten beyond the layers one builds up to survive in this world. And in shedding the burden of those layers, I also shed the weight of shame, insecurity, and negativity that has been so heavy since I was a kid. It’s not gone. But the load is immensely lighter.

The benefits of this framing showed up for me last weekend. All our adventures, including an impending critical meeting at work, caught up to me, and my mind spun late into the night. I wasn’t tired; I began worrying about everything. I was transported back to a solitary room in Avenue Hospital in Nairobi, where I stayed for two days and thought my only way out was to float through the wall. I felt fearful, anticipating another episode of psychosis and how devastating that would be for my family and me.

But I got through it, because of the four Ps: I woke my wife beside me, who comforted me by making me truly know that she was there for me; later, I spoke with my therapist. We were in a place where I could spend the weekend resting and being cared for, without having to worry about what it would cost. Our daughter was next to us, and my wife reassured me that she would absolutely feel my love for her when I worried. And I recognized that it was time to take my anti-psychotic pill, despite its unwelcome side effects, because I know from experience that I needed to sleep.

I would be lying if I said I wasn’t a bit nervous about our trip back. I’ve had enough adventure for one year, let alone one trip. But if life does happen to throw us another curve ball, I’ll either swing at it or watch it go by. But you can bet I won’t let it throw me off balance.

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Peter Varnum is the Chair of the Board of The Stability Network and Associate Director for Orygen Global, looking after Orygen’s collaboration with the global youth mental health community. Prior to Orygen, he built and led the World Economic Forum’s work on global mental health. He also serves on the Healthy Brains Global Initiative’s Lived Experience Council. He earned a BA in English from Carleton College and an MA in Law and Diplomacy from The Fletcher School at Tufts University and completed the World Economic Forum’s Global Leadership Fellows executive education program.