On the Difference Between Community Health and the Industrialization of Distress
Paul Tan · Good Protocols, SPC · April 2026
Culture care is an act of generosity to our neighbors and to the future.
Makoto Fujimura, Culture Care
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In the summer of 2025, King County announced that its crisis system had served 106,000 individuals in a single year. Nearly 82,000 of those were anonymous contacts on a crisis line. The county presented this as progress. It is progress of a kind. People who called did not die alone. The naloxone in the vending machines has reversed more than 800 overdoses.
What is this actually showing us? We are losing grasp of something in the numbers.
I don’t want to make a critique of crisis response. The question is about what this crisis response at this scale is telling us. How did we get to this stage of our community where crisis seems to be everywhere. There is a difference between building a pipe to manage the output of a broken watershed and restoring the watershed itself. We are really skilled at building pipes. We build them faster and with seemingly unlimited public funds. But we are losing something in the acceleration that we will not be able to rebuild once it is gone.
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The Watershed
Before this last generation, people in distress did not call a line. They went next door. They went to the grandmother. They went to the congregation, the neighborhood, the uncle who had been through something similar and survived. The support was not professional or evidence-based. It was not available 24/7 regardless of insurance status.
It was human. We assumed that there was some relationship that had a before and an after. The neighbor who sat with you through a hard night knew your name last Tuesday and would know it next Thursday. The pastor who talked you off the ledge had also baptized your children. The uncle who understood your particular darkness had shared a table with you long enough that the table itself was part of what held you.
This is what Hartmut Rosa calls resonance: the living, responsive encounter between a self and a world that answers back. Not happiness. Not the absence of suffering. The circuit of genuine meeting, in which I speak and the world is moved, the world speaks and I am moved, that produces the felt sense of being in real relationship with one’s own life. Rosa spent a career documenting what acceleration has done to those circuits. The compression of time. The fragmentation of community. The instrumentalization of every relationship until nothing is done for its own sake. The result, across decades of late modernity, is a world that has largely gone quiet. A world that does not answer back.
That silence is not a mental health crisis in the clinical sense. We have a crisis in the conditions under which humans become themselves, discover what they carry, and find communities in which what they carry is heard and needed. The mental health metrics, the rising rates of anxiety, depression, loneliness, the youth mental health crisis Jonathan Haidt documents, the addiction epidemic Gabor Maté traces to disconnection, these are the measurable signature of the silence. They are not the silence itself.
The watershed is the dense, intergenerational, reciprocal life of a community with enough time, stability, and commitment to know its members across the long arc of a life. It held most people most of the time. Not perfectly. Not without harm. The village could be cruel. The congregation could be narrow. The uncle could be the source of the wound he was expected to heal. But the water moved. People were formed in relationship over time. They arrived at difficulty having of a hundred encounters that had built something load-bearing inside them.
Then modernity arrived. Then acceleration. Then mobility and fragmentation and the great dispersal. Sunday dinners thinned to holidays, then to door-dash alone. The neighborhood that once held every kid became a collection of private houses with garage doors that close automatically or multi-floor highrises that act more like storage units. The bowling leagues disbanded. The congregations hollowed. The Saturday cooking that fed Sunday’s gathering stopped when the grandmother died and no one had learned the recipes. The watershed drained.
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The Pipe
Our response was not to restore the watershed. It was to build pipes.
Childcare to replace the grandmother’s kitchen. Counselors to replace the neighbor. Crisis lines to replace the uncle. Mobile response teams to replace the congregation’s capacity to sit with someone through the night. These are not malicious substitutions. They arose from genuine compassion in the face of genuine suffering. People were falling and there was nothing there to catch them. The pipes deliver something real to people in real need.
But a pipe is not a watershed. And the professionalization of distress response does something to the surrounding terrain that the pipe itself cannot see from inside its own logic.
Alexis de Tocqueville traveled America in the 1830s and came back with a warning that reads like a forecast of what we have done. Democratic freedom, he observed, carries a danger: severed from the bonds of fraternity and moral community, it collapses inward. The free individual, liberated from the obligations of tradition, finds himself alone with his own desires, and when those desires grow hollow, there is nothing communal left to fill them. His prescription was voluntary association: the thousand small organizations through which Americans gathered to solve problems, hold each other, and practice the habits of self-governance. Not government programs. The neighbor, the congregation, the mutual aid society. The things you build because you live together.
What Tocqueville could not have predicted is how thoroughly government infrastructure and the nonprofit sector, built with sincere compassion, would displace the voluntary associations he praised. Not by force. By convenience. By supposedly being better at the immediate problem. By making the neighbor’s awkward, inadequate presence feel redundant when a trained “professional” is available 24/7. How many 10 year plans to end homelessness can we expect to renew before we realize the unhoused are without a place they call home?
Every government function that displaces a civil society function makes the civil society function harder to rebuild. Once the fifth branch of public safety exists, police, fire, EMS, 911, and now mental health crisis response, the neighbor who would have sat with someone has a number to call instead. The call is easier than sitting. The sitting stops happening. The capacity atrophies. The system has produced its own permanence.
This is not the system’s fault. It is the system’s logic. King County’s Crisis Care Centers levy will invest over $160 million in the behavioral health workforce over nine years. That workforce will grow. It will become infrastructure. Infrastructure becomes assumed. And the community that would have held the function, had it been asked to, had it not been relieved of the obligation, learns, over a generation, that mental health is a professional matter.
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The Shape of a Life Formed Inside the System
Consider what happens to a person formed from the inside of this infrastructure over two decades. Not the genuinely ill. That population is real, it is a minority, and it deserves everything the system can offer. The infrastructure built for them is legitimate hull work.
But the infrastructure never stays contained to that population. It expands. The therapeutic framework, the language of trauma, diagnosis, crisis, professional support as the appropriate response to difficulty, has spread well beyond the population for whom it was accurate, into a general cultural grammar for understanding ordinary human suffering.
Scott Barry Kaufman’s sailboat is the clearest frame for what this produces. A healthy person has both hull and sail: the security needs that form the vessel’s foundation, and the growth needs, exploration, love, purpose, transcendence, that the sail catches. Hull without sail is a boat that floats but goes nowhere. The elaborate crisis infrastructure being built across our cities is hull work. It addresses the breach, stabilizes the vessel, prevents sinking. What it cannot do, by design and by funding logic, is hoist the sail.
The young adult being formed inside this infrastructure learns, early, to read their own interior life through a clinical lens. Normal developmental hardship, conflict with peers, academic struggle, the pain of first loss, the exhaustion of growing up and the swings of hormones, gets named in therapeutic language before the young person has encountered the older, harder-won languages that communities once used to hold such experiences. The therapeutic language captures real phenomena. But it is thin. It does not carry the accumulated wisdom of tradition, faith, communal narrative, intergenerational witness. Everything becomes symptom and intervention.
And the posture it teaches, that your interior life is a clinical object, that difficulty is a signal to access professional help, that your own emotional experience is the authoritative data about what is happening to you, is not a posture of strength. It is a posture of permanent, low-grade dependency on a framework that can only be delivered by credentialed others. The young adult who has internalized it has been taught to understand themselves as someone who requires professional management to function. The management may be light. The message is heavy.
This is not a failure of anyone’s care. The counselors may be skilled. The trainings are well-researched. The crisis lines are staffed by compassionate people. But the cumulative effect, across a generation, is the raising of a particular kind of human being: the diagnosed dependent. Not broken or failing. Formed into a relationship with their own difficulty that always requires external professional architecture to navigate, in a world where that elaborate architecture cannot actually be present in every room of every life.
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What Culture Care Sees That the Debate Cannot
The public conversation about mental health infrastructure is a culture war in slow motion. One side points to the suffering and says: build more, fund more, credential more, respond faster. The other side points to the outcomes and says: the system is not working, the spending is producing dependence, the therapeutic culture is making people fragile. Both sides are partially right. Both are fighting over the pipe while the watershed continues to drain.
Makoto Fujimura’s culture care refuses this war entirely, not as a diplomatic maneuver but as a philosophical commitment. The artist’s vocation, he insists, is soil preparation. Not content production or the contest over which side’s pipe is more efficient. Culture care means tending the conditions in which human flourishing becomes possible, over a generational horizon, without demanding to see the harvest before the planting is done. The most important work happens before the crisis, in the unhurried, relational, simple work of building the kind of community where crisis is less inevitable.
This is not a passive posture. Soil preparation is labor. It is specific, material, unglamorous work. The cook who puts the handmade cloth on the table before anyone arrives to a function is doing soil preparation. The neighbor who crosses the street to learn a homeless young man’s name, not to report him, not to manage him, but to know him, is doing soil preparation.
These acts do not appear in any levy report. They produce no metrics and cannot be funded by a government agency because they cannot be contracted, credentialed, or quality-assured. They are what a community does when it has decided that the people in it are worth knowing across the long arc of a life.
The kintsugi insight runs through everything Fujimura has written: the broken vessel is not discarded. It is mended with gold, and the mending makes the fracture visible and beautiful rather than hidden. But the mending requires a maker who knows the piece, who understands what it was before it broke. The crisis system receives the broken piece with no knowledge of what it was. It wants to stabilize the fracture. It does not know what the gold would look like, because it was not there for the history that preceded the break. Only community has that knowledge.
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The Young Man in the Car
There is a young man living in his car in a friend’s neighborhood. The neighbors have approached him. He is somewhat centered in his own thoughts, his narrative not entirely full, but there is coherence enough to a story that is still forming. His car is accumulating things. Not waste (yet). Accumulation.
The physician who lives across the street does not know when to call 988. He knows this neighbor is in a precarious place. He also knows that 988 routes to crisis response, and crisis response is a hold-or-release decision that will assess, find no hold criteria if the young man is not imminently dangerous, and leave, possibly damaging the relationship the neighbors have spent weeks carefully building. The system is not designed for this situation. It is designed for the acute moment, not for the patient accompaniment of someone whose trajectory is concerning but whose crisis has not yet peaked.
The neighbors are the intervention. They are doing something the levy cannot purchase and the fifth branch cannot replicate. They are being present across time. They are learning his name. They are offering food as though they have extra, because they do not want to confirm a story he may already be telling himself about being someone who needs charity. They are building a small, informal accompaniment structure out of nothing but proximity and willingness to show up.
This is the watershed function. It is precarious. It depends on two particular people who happen to live on that street, who happen to be the kind of people who cross the street rather than call the line. It is not scalable. It does not appear in any outcome report. If it works, there will be no record of what made it work. The formation happened in the space between people who were simply present to each other over time.
If it does not work and the trajectory continues and the intervention eventually required is clinical or legal, the system will receive him at that point as a new case with no history. The weeks of patient neighborly accompaniment will be invisible to the system.
A healthy society would know how to receive it. It would recognize the neighbors’ investment as the most important infrastructure in the situation, and it would build any professional response on top of that foundation rather than replacing it. It would train the physician not to call 988 but to call a colleague directly, and to frame that call as: there are people here who have been building a relationship with this young man for weeks, and we want to support what they’ve built rather than disrupt it. The clinical intervention, if it becomes necessary, would be offered as an extension of the accompanying relationship, not as a stranger arriving in a crisis moment with a checklist.
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Two Lines Rising Together
Here are the numbers. According to the 2023 National Survey on Drug Use and Health, nearly one in three American adolescents, approximately 8.3 million young people between ages 12 and 17, received mental health treatment in the past year. The figure has grown steadily for more than a decade. Young adults ages 18 to 26 are the highest-utilizing age group in the country. In public schools, 97 percent now offer some form of mental health services, and on average 19 percent of the student body is actively engaged with them. More than half of schools report that the number of students seeking those services increased from the prior year.
Now set that alongside the yet more troubling data. The CDC’s 2023 Youth Risk Behavior Survey reports that 40 percent of high school students experienced persistent feelings of sadness or hopelessness, up from 30 percent a decade earlier. National Survey of Children’s Health data indicates that nearly one in three youth ages 12 to 17 had a mental, emotional, developmental, or behavioral problem in 2022-2023.
Two lines are rising together. The treatment line and the distress line are climbing in parallel. A generation ago, the standard assumption would have been that expanding treatment would, over time, reduce the underlying distress. That is not what the data shows. The infrastructure is scaling but the suffering it was built to address is not receding.
This is the pattern that deserves our attention, because the public conversation does not know what to do with it. One side reads the distress number and argues for more capacity. The other reads the treatment number and argues for cultural pushback. Both are missing the structural question the parallel climb actually raises.
The question is whether the framework itself, treating ordinary developmental difficulty as a behavioral health condition requiring professional intervention, is producing, rather than reducing, the category of young people who identify as needing that intervention. Not cynically or through anyone’s intention. Through the internal logic of any system that expands to meet a need and, in the expansion, teaches the population it serves to understand themselves through the system’s categories.
Maia Szalavitz’s work on addiction as a learning disorder applies here beyond its intended frame. The nervous system learns what regulates it. If what regulates distress is always external, the counselor, the line, the mobile team, the crisis center, the internal regulatory architecture that comes from tolerating difficulty in the presence of people who know you does not get built, because it keeps getting preempted by the infrastructure “doing its job.” A generation whose regulation is externally dependent is a generation that will require the infrastructure to remain in place to function. The dependency is not a character flaw. It is a predictable outcome of the formation environment we constructed.
And here is the cost. When treatment utilization approaches a third of the adolescent population, the person with florid schizophrenia who cannot survive without intensive clinical support is waiting for a bed that is occupied by someone whose suffering is real but whose actual need is the restoration of relationship and community. The system cannot make this distinction. It has not been designed to. It serves everyone presenting in distress through the same professional framework, regardless of what the distress actually requires. The genuinely ill minority and the much larger population experiencing the ordinary suffering of a resonance-poor world are receiving the same response, and neither is being served well by it.
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This Is Not Okay, and We Can Do Better
We are making a generational mistake. Not in the existence of crisis infrastructure. Some of us, including in my own work across thirty years, have fought to build it for people who had no one, and that fight was right. The mistake is in the pace and the scale. We are building the fifth branch faster than we can see what it is doing to the first four. We are expanding a professional response to human suffering at a rate that is outstripping our capacity to examine whether the response is producing the outcomes it promises. And we are doing it with a confidence the data does not support.
Slow down. That is the first thing a healthy society does. It does not expand an infrastructure that is not reducing the suffering it was built to address. It pauses. It asks what the numbers are actually telling us. It treats the parallel climb of treatment and distress as a signal that the framework itself needs examination, not as evidence that we need more of the framework.
We can do better. We can do better without abandoning anyone who is genuinely ill. We can do better without rapidly building a new layer of infrastructure on top of the one that is already failing to produce the outcomes it claims. We can do better by putting the same seriousness, the same funding, the same cultural attention into the watershed that we are putting into the pipe. And we can do it now, because the communities that remember how to do this work are still present among us, in immigrant neighborhoods, in congregations, in mutual aid networks, in the rooms where the grandmothers still know the recipes.
A healthy society invests in the watershed with the same seriousness it invests in the pipe. It asks: what are the conditions under which communities develop the capacity to hold their own members across the long arc of distress, without requiring professional mediation for every difficulty? What does it cost a community to develop that capacity, and what does it cost a community to lose it? It treats those conditions as primary, and the professional infrastructure as the safety net for the cases that the conditions cannot hold.
This means investing in a Slow Table, not as a program, but as the unglamorous, patient work of building the shared meals, the regular gatherings, the communal practices that produce the residue of knowing each other across time. It means investing in the grandmother’s capacity to carry her formation technology into the next generation, the recipe, the proverb, not as cultural programming but as the genuine transmission of what she knows about how to hold a person through difficulty. It means training the physician across the street not in 988 protocols but in the art of patient accompaniment: how to be present to a neighbor whose situation is concerning without converting the concern into a clinical referral that severs the relationship.
It means resisting the acceleration logic that makes professional response feel more efficient than community presence. The neighbor who crosses the street is slower than the mobile team. The grandmother’s table is less accessible than the crisis line. The congregation that has known a family for twenty years is harder to replicate than a 24/7 service. But it is only the slower, harder, irreplicable thing that builds the kind of person who can inhabit their own life without requiring professional management to survive it.
Rosa calls this the uncontrollability condition: genuine resonance cannot be produced by control. The world that answers back cannot be engineered into existence. It can only be tended, with patience, over a generational horizon, without the expectation of metrics that the tending will never produce.
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The Kintsugi Society
There is a scene in a community center in south Seattle on a Friday night. The cook puts a cloth on the table before anyone arrives. Not because it is required. Because the cloth is part of what makes the table a table rather than a surface. A young man measures rice for twenty-seven people with a precision that surprises everyone, including himself. A grandmother puts her hand on a young autistic woman’s hand after the music stops and says something in Tagalog that the young woman does not understand and yet understands completely.
Nothing in that room is clinical. Nothing is evidence-based in the sense the system recognizes. The cloth is not a therapeutic intervention. The rice is not a skills-building exercise. The grandmother’s hand is not a co-regulation protocol. The room is formation happening in the only medium in which formation actually happens: a community of people who have decided that the people in it are worth knowing, and who have shown up enough times that the nervous system has accumulated sufficient evidence to begin to lower its guard.
This is the kintsugi society. Not a society without fracture. Fracture is the condition of every person in that room, and of every person in every room in late modernity. But a society that has decided to mend what is broken with gold rather than hide it, to build communities in which the fracture is visible and the mending is made beautiful, to invest in the long, patient, unglamorous work of soil preparation rather than the efficient delivery of crisis response to people whose crisis was, in many cases, the predictable outcome of a world that stopped answering back.
The levy will be renewed. The fifth branch will expand. The infrastructure will grow more sophisticated, more accessible, more culturally responsive. These are not nothing. But they are not the watershed.
The watershed is built by the neighbor who crosses the street. By the grandmother who carries the proverb. By the cook who puts the cloth on the table. By the physician who stays rather than refers. By the community that decides it will know its members across the long arc of a life, not as cases to be served but as people whose frequency is worth hearing.
That is culture care. That is what no levy can fund and no system can replicate. That is the only thing that has ever, in the history of human communities, actually worked.
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Paul Tan is the founder of Good Protocols, SPC, a social purpose corporation based in South Seattle’s Rainier Valley. He has spent thirty years in executive nonprofit leadership across youth homelessness, foster care, refugee resettlement, anti-trafficking, and multicultural family programming in the Puget Sound region. He is also a finish carpenter and furniture maker. goodprotocols.org