The New Psychiatry

More than 30 years ago, I chose to go into psychiatry because I’d always loved the humanities, creative problem solving, and collaborative teamwork. After earning my degree, I was thrilled to be hired by a staff-model HMO, where I had great colleagues, visionary leaders, and many grateful patients, whom I loved helping get better. But my role as a psychiatrist was clearly defined there as a medication prescriber, nothing more.

Feeling deeply that something was missing in how I was practicing, I left the HMO after five years to work in a primary care system, staffed with a progressive group of family physicians and nurse practitioners. I thought this would allow me to work more holistically. Instead, I felt isolated from my mental health colleagues and entirely overwhelmed by the demands for—you guessed it—medication management.

The kind of psychiatry I was practicing back then—the same kind I saw practiced all around me—was not what I’d envisioned when I’d chosen to be in this field. Through forces outside of my control, but with my passive consent, I’d unintentionally become a psychopharmacologist. My role was to make rapid assessments, do crisis management, prescribe medications, and manage those medications and their side effects. For psychiatrists, the 50-minute therapy hour had become the 15-minute med check.

Most of my patients were suffering from some form of depression, and I’d see an average of four new patients a day, because the demand for meds was so high. Many of these patients were in crisis; many were suicidal. I’d often go home in the evenings feeling completely drained and weighed down by the awareness that a dozen or more of my patients were at serious risk of harming themselves. Seeing about 20 patients per day, five days per week, I sat with a lot of depression. Although many of my psychiatric colleagues were seeing many more patients than I was, I was overwhelmed.

I’d always imagined doing a deeper kind of work, where I’d have time to get to know my patients more fully and apply all my knowledge and skills, not just those for diagnosing and prescribing. But the field had changed, and I found myself isolated in a world of assembly-line patient contacts and rigid treatment protocols. While modern psychiatry was certainly bringing good work to the world, I wasn’t sure that it was my work. I couldn’t imagine doing it for another 25 years.

I recall meeting with a patient one day who was really pleased with his response to Zoloft. “So this is how I’m supposed to feel,” he said. I was glad to see him feeling so well after so many years of depression, but as I shook his hand at the end of the session, it dawned on me that I didn’t feel like I was supposed to, not even close. In fact, many of my patients seemed to be feeling better than me.

I went directly to the closet where medication samples were kept and gazed at the boxes of Zoloft, Lexapro, and the like. Should I be trying one of these? I asked myself. I had no problem with the idea of medication, and still don’t. I see it as a legitimate tool for people who need support for their mood. Although I was feeling a bit depressed, it wasn’t clinical at that moment. I had a young family and was experiencing a lot of everyday stress, but something else was gnawing at me: still early in my career, I was already burning out.

Rather than taking medication, I knew I needed to do something about my work. But what? I felt as if I was walking in a slot canyon, and with each step the walls were getting higher and the path narrower. If I kept going, I feared I’d become entirely stuck. How did it come to this? I wondered. And what’s the way out? I didn’t want to stop seeing patients, but the work seemed so soulless. Is it still possible to blend science with soul? I asked myself, realizing that’s what I wanted to do.

The Need for a New Psychiatry

Given how dramatically it’s changed in just a short time, it’s easy to forget how young the field of modern psychiatry is. Born in Europe during the Victorian era, early psychiatry focused on the unconscious drives that created the “neuroses.” Freud, the most famous of the early psychiatrists, believed that psychiatric illnesses had a biological basis, and that people could recover from them if unconscious drives and beliefs could be made conscious through talk therapy.

For years, variations of this thinking ruled the field of psychiatry, but while psychodynamic treatment offered a deep understanding of one’s inner motivations, it was long, slow, and expensive. Training itself took many years at great expense, and few clinicians were in practice at a time when the world was starting to need them more and more.

Since World War II, the United States in particular has seen the number of people suffering with stress-related problems, like anxiety and depression, steadily rise to alarming levels. Depression has long been the primary cause of disability in the US, and it’s soon expected to be the major cause of disability worldwide. In fact, a survey from the National Center for Health Statistics shows a dramatic 24 percent rise in suicides in the US between 1999 and 2014, particularly among women. Clearly, there’s a need for large-scale, easily accessible, and effective forms of treatment and prevention. But the long-term individual therapy embraced in the past couldn’t meet this growing necessity.

It wasn’t all that long ago that people mostly paid out of pocket for their medical care, and only those with means could afford psychotherapy. At first, when large numbers of people became insured, access to treatment increased greatly, and more therapists were trained in several different fields. Inevitably, however, insurance costs became ever more tightly managed, and the more expensive providers of therapy—namely, psychiatrists—were unable to justify their higher costs. For many, it meant giving up their practice altogether.

Meanwhile, the field of psychopharmacology exploded. The earliest antidepressants were discovered in the 1950s, when the tricyclics, actually intended for other conditions, were seen to lift patients’ mood. People with severe depression were so grateful for any relief that they were willing to take these drugs, despite their many known side effects. This opened the door to creating new drugs, expressly meant for conditions like depression—and this created a greater need for medically trained professionals to prescribe them.

When I was with the HMO in the early 1990s, we staffed about 15 psychiatrists and 100 psychotherapists. By then, SSRIs like Prozac and Zoloft had become the mainstay of psychiatric treatment. They were seen as low-risk, well-tolerated medications, yet there was some reluctance among my therapy colleagues to refer their patients for meds. The prevailing attitude seemed to be that medications might suppress the emotions needed for productive psychotherapy.

But by the time I left, just five years later, the pendulum had swung, and the belief among therapists seemed to be that therapy could be faster and more effective with the help of the new meds to relieve anxiety and depression. The referrals were coming so fast that the psychiatrists simply couldn’t keep up. Psychiatry went all in on the biological model of depression. The National Institute of Mental Health labeled the 1990s the “Decade of the Brain,” and there was great optimism, which I shared, about finding a cure for depression through improving brain chemistry.

As I observed and participated in this transformation of psychiatry, I wondered how much it was driven by a desire to align more closely with the rest of medicine. After all, it was widely perceived that our medical colleagues considered psychiatry to be different from other medical specialties. I often heard phrases like “psychiatrists aren’t real doctors.” Embracing the biological paradigm, ordering tests, following treatment protocols, and prescribing medications like every other doctor seemed to lend our field some longed-for legitimacy.

For all practical purposes, we gave up on psychotherapy. Since insurers told us they wouldn’t pay for psychiatrists to do therapy, we didn’t do it. Training programs added more and more biological curricula at the expense of psychological training. As we learned less about therapy and had less experience doing it, we stopped thinking psychologically, not to mention soulfully. We focused on smaller and smaller aspects of the human condition. We voluntarily diminished ourselves.

The Endless Cycle

Today, medication management remains the primary role of most psychiatrists. In my view, it’s not working well, either for our patients, or for ourselves. My patient Shelly is an all-too-common example of what I see every day in my practice. Twenty years ago, she left her well-paid but stressful job so that she could be at home with her three young children. At about the same time, her family moved to a house that needed a lot of work, and her husband unexpectedly lost his job. She was overwhelmed with anxiety, which morphed into depressive symptoms.

Shelly began seeing a therapist who referred her for a medication evaluation. She was prescribed the SSRI citalopram (Celexa), and her symptoms improved. But after a few years on citalopram, she felt increasingly sluggish and emotionally flat. Wellbutrin was then added to boost her energy and mood. She stayed on that combination for 15 more years. She gradually gained weight and never felt very happy or energetic, though her mood was stable. Then about three months ago, she abruptly went off both medications. At first, she felt better, but by the time she’d come to see me, she was feeling more anxious and depressed than ever.

Shelly was diagnosed with major depression, but after hearing her story, I thought a more accurate diagnosis would’ve been an adjustment disorder. Why does it matter? Because while they may feel and look alike, major depression and adjustment disorders are quite different. I consider major depression to be more often genetic, physical, and responsive to medications or other biological therapies; whereas an adjustment disorder is stress related, should be temporary, and is best addressed by reducing the source of the stress and learning new skills. Medications, if needed, should be used briefly, while these other measures take hold. But that’s not how they’re commonly used today. Like Shelly, more and more people are taking antidepressants long-term and not being guided toward dealing with the sources of their stress.

Let me be clear: I believe there’s a role for medications in treating all forms of depression. However, offering them as the primary—and often the only—treatment for years and years is simply not working. And that’s what we’re doing on a very large scale. We’re in the midst of a massive, uncontrolled experiment with prescribing, and the outcome doesn’t look good. Recently, the National Health and Nutrition Examination Survey showed that about 35 million American adults took antidepressants between 2013 and 2014, nearly half of them for longer than five years. It would be one thing if that were the end of the story, except millions of people stay on meds long-term, even when they stop working, or, as is sometimes the case, make things worse.

It may take a few months to show up, but several common side effects that develop from long-term use of medications can easily be confused with ongoing depression: flatness of mood, low energy, weight gain, apathy, loss of interest in sex, and lack of motivation, to name a few. I often interpret these problems as a sign that the medication dose is too high, but I fear many clinicians see them as signs of ongoing depression and respond, as with Shelly, by prescribing more medication.

If one truly has recurrent major depression, then staying on a medication might be the best course of action. But prescribing too quickly and for too long puts people with adjustment disorders at risk. I frequently see patients, like Shelly, who were prescribed medications for a stress-related problem, stayed on them for years, saw their effectiveness wane, and then struggled mightily through significant withdrawal to get off of them.

The brain changes after being on a drug in ways that can make it hard to stop taking it. After being flooded with serotonin, the receptors get used to it. They shrink in number, or become less sensitive to the serotonin molecules than before. That process is called down-regulation. If you pull the medication away, shutting off the flow of serotonin, the brain typically struggles to adapt to this state of deficiency.

Sometimes there can be a rebound of the depressive symptoms that may be worse than in the initially presenting problem. This is often interpreted as a recurrence of illness when in reality it’s just withdrawal from the medication. Unfortunately, the symptoms of withdrawal can persist for so long and be so severe that many people choose to go back on their meds, whatever the side effects. And who can blame them?

The Rise of Natural Mental Health

Ironically, while psychiatry was becoming more reductionistic, other areas of medicine were becoming more holistic. There was a growing interest in mind–body and natural medicine, driven in large part by consumers themselves. Surveys revealed that a huge percentage of Americans were flocking to more natural therapies, and they were spending surprisingly large amounts of money doing so.

In 1993, public television broadcast Bill Moyers’s Healing and the Mind, a groundbreaking series, which helped speed this transformation. Like many viewers, I was fascinated by the episode about a young scientist named Jon Kabat-Zinn, who’d begun teaching the Buddhist practice of mindfulness in a major university hospital in Massachusetts. I set out to train with him in Mindfulness-Based Stress Reduction (MBSR) that very year, along with thousands of therapists and other healthcare professionals who’d go on to incorporate mindfulness principles into their practices.

My experience with MBSR helped me realize that I could practice psychiatry in ways that were not only more helpful to my patients, but more meaningful to me. Indeed, I began to imagine that I could step out of the professional role defined for me by others and practice in a more wholehearted way. Back then, I did this by starting to teach MBSR classes at the HMO. I called it group therapy, since the HMO didn’t yet know what to do with it. Suddenly, therapists began referring patients to me, not just for medication, but for meditation. By the end of the eight-week program, most participants felt better. Many relied less on both medication and on psychotherapy.

MBSR also changed my approach to the rest of my work. I learned to be more patient and give people a bit more time to improve. They didn’t have to feel better immediately—an expectation often set up by medication. I learned to take into account their health and wholeness, not just their pathology. I began to trust that the body and mind could heal themselves if given the time and space to do so.

But even with this new perspective, I was still stuck in the prescriber role 95 percent of the time and didn’t see a clear way out. Then one day, as I was driving my son to his soccer game, I happened to notice a bumper sticker on the car in front of me. It read: “Surely joy is the condition of life.”

Nice sentiment, I thought, but does anyone really buy that? Then I paused and looked over at my young son. Perhaps Thoreau, whose quote was on that bumper sticker, was onto something: perhaps we’re always immersed in joy, even when we’re mired in sadness or hardship and can’t see or feel it. For me, that was a moment of awakening, and it helped me turn the way I viewed depression on its head. Maybe my real job wasn’t limited to giving temporary relief through medication, but to help my patients release whatever blockage in their body–mind–heart was keeping them from their natural state of joy.

To understand this better, I decided to take a sabbatical year and study with people who I felt were at the cutting edge of the natural health field at the time. I studied natural therapies with C. Norman Shealy and Andrew Weil. I began to awaken my intuition in classes with Caroline Myss, and to open my heart in retreats with Tara Brach. I learned about Ayurveda from Deepak Chopra and David Simon. I trained in mind–body medicine with James Gordon, the first psychiatrist I’d worked with who’d developed an approach to practice that embraced these new ideas.

These people, and many other like-minded therapists, psychiatrists, and other physicians, are part of a movement changing the conversation about modern healthcare that incorporates more integrative, holistic approaches. I now believe that we’re on the verge of a new psychiatry, much different from what we’ve seen for the past 30 years. The changes I’ve made in my own practice reflect this shift, blending science and soul in a way that encompasses the whole person.

A New Psychiatry

After a bit of meandering, I’ve found my professional home in Partners in Resilience, an integrative clinical and teaching entity, where I collaborate with several therapists, an integrative nutritionist, a health coach/spiritual director, yoga teachers, and others. We offer resilience-training programs for adults, teens, and health professionals, as well as holistic, integrative work with individual clients. It’s where I do my clinical work, which I now approach in a new way. There’s more joy in it for me, for sure, and I believe there’s more joy in it for my patients.

Begin with a Paradigm of Wholeness. It’s hard to imagine a health condition that affects more aspects of the human condition than depression. And I now work from a model, developed over many years, that delineates three stages in the path from depression to joy: nourish, move, awaken.

Stage one of nourishing involves providing whatever is needed to return to a healthier state. I think of it as the recovery stage, where what’s been depleted is restored, stress-management skills are learned, and patients begin to shift from isolation to connection with others. In our program, we use diet, nutritional supplements, and medication to address the physical; mindfulness skills to address the mind and emotions; and practices like metta meditations and group experiences to open the heart.

Stage two of moving shifts from recovery to prevention. Hopefully, most of the original symptoms have resolved enough at this point, allowing the patient to take action—wise action—to create more lasting and meaningful change. This includes physical movement, like walking, yoga, or breathing practices, but also creating movement in stuck mental and emotional patterns. Good psychotherapy is part of this stage, and so are groups or classes devoted to deepening mindful awareness, self-acceptance, and the cultivation of positive emotions, such as gratitude and compassion.

Stage three of awakening I consider the thriving stage. One can awaken the senses and enhance their capacity for pleasure, the mind’s curiosity and creativity, and the heart’s capacity to learn how to love well and live more authentically. Some may say that this isn’t the purview of the mental health profession, but I’d argue that going beyond a return to baseline functioning to a state that more resembles joy can be a necessary protection against depression’s recurrence. I believe it should be an essential part of our work.

Change Your Relationship with Time. I still work as hard as I did in my psychopharmacologist days, but my work now involves more than direct patient care. I also spend time writing, speaking, facilitating workshops, or planning new programs. Even though I suspect I work more than ever, it doesn’t feel that way. I enjoy everything that I’m doing so much that I seldom even think of it as work.

I limit my clinical work to three to four days per week, aiming for about six hours of direct patient contact per day. I spend at least an hour every day responding to patients’ questions or requests, but that, too, is something I enjoy and see as valuable. I spend 60 to 90 minutes with each new consultation, depending on the complexity. All my follow-up sessions are at least 30 minutes. I seldom feel rushed, and when I do, I’m reminded of what I used to feel like all the time and take measures to adjust my schedule. I’m all for efficiency—and I believe that I’m more efficient now than before—but I don’t see the value in pushing clinicians to squeeze more and more patients into their day. To be effective, I believe we need to be fully present. For me, at least, that means working at a human pace.

My time with patients feels leisurely now, and I have a chance to get to know them much better. I enjoy it so much that I intend to continue for a long while yet, even though more and more of my cohort of psychiatrists are retiring or wishing that they could. The majority of my work is with complex patients, and I find the work immensely satisfying because so many people feel better even though we often reduce their medication, or perhaps because we reduce their medication.

Focus on the Good. Medical training is focused almost entirely on pathology. I suspect that’s somewhat true for psychotherapy, too. Of course, we’re trying to treat illness, but I think this focus puts blinders on us. Eventually, all we can see is what’s wrong; everything becomes a problem that needs to be fixed.

For several years after my sabbatical, I helped health professionals find a sense of renewal in a program that I called The Inner Life of Healers. Based on the work of Parker Palmer, founder of the Center for Courage & Renewal, it involved a series of weekend retreats that encouraged deep reflection on questions related to “soul” and “role.” In other words, it helped participants bring their whole self to work, to try to live more authentically in their work lives.

One of the core skills was deep listening. You’d think that physicians would be good at that, but most in the groups I ran were so inclined to look for what was wrong that they really struggled to listen without asking leading questions or suggesting ways that the person could fix things. It took several weekends for them to begin to unlearn their old strategies. I learned through mindfulness training that there’s more right than wrong with any person, and that so long as a person is breathing, there’s still time for healing and wholeness.

When I remember to look for the good in others, I’m much likelier to be able to help them become a better version of themselves. Often, patients have a hard time picturing this version, but if we can hold the vision of what’s possible, and then convey that to them, they’re likelier to get there themselves. Some of the most resilient people I know have a severe mental illness: they keep trying, keep getting up each time they’re knocked down by their frayed genes or their unfortunate early circumstances.

Mental illness is just like any illness: sometimes it just happens, no matter how well patients keep to their self-care routines or how good the treatment they receive. We as clinicians have to keep seeing the mighty warrior, the light inside them, even in their darkness. They don’t need to be fixed so much as they need to be held in awareness as their light returns.

Offer Individualized Solutions. I think we tend to see depression as a singular condition, but it’s not. If our diagnostic labels were more sophisticated, we might be better at identifying the underlying causes for each individual’s depression and then offering specific recommendations best suited for that person.

I see depression as having three different patterns, or subtypes. Most patients fall into one category, but sometimes they have features of two, or even all three: anxious mood, agitated mood, and sluggish mood. The anxious mood is the most common pattern, in part because it’s driven by stress. It often represents an adjustment disorder, rather than outright major depression. People in this category often have trouble sleeping, especially falling asleep, become easily overwhelmed and reactive to stress, and feel insecure or insufficient. They tend to withdraw and find it hard to put themselves out into the world.

The agitated mood is often missed because people don’t usually come to your office and say, “I feel agitated.” They describe their mood as “bad” or “depressed,” and you have to ask questions to tease it out. This is important because agitation can increase the risk of self-harm or suicide, especially when first starting an SSRI antidepressant. It’s characterized by an edginess to the mood, as well as anger or irritability, often accompanied by physical restlessness and impatience. Sleep is a common problem here as well, but the pattern is more often waking in the middle of the night and ruminating, sometimes for hours.

The sluggish mood best fits with what used to be called melancholia or melancholic depression, where people have a hard time getting out of bed or off the couch. The mood may be sad and down, or just flat and apathetic. The mind can feel lethargic, and it can be hard to get motivated or to experience pleasure. Sleep may be excessive, and getting up in the morning can be difficult.

Safe Natural Therapies First. Functional medicine is a fairly new way of looking at illness, one that tries to get at the root cause through a better understanding of the body’s normal function and what disrupts it. Instead of using an antidepressant that manipulates serotonin, for example, a functional physician might change the diet to reduce systemic inflammation or add micronutrients to get the serotonin system working properly. Functional medicine is complex and requires a sophisticated understanding of biochemistry and physiology.

There was a time when I saw myself as a “naturopathic psychiatrist” and wanted to be done with prescribing medications altogether. But before long, I realized I was still being reductionistic, just in a different direction. Medication is just another tool, neither good nor bad. It made no sense for me to throw it out altogether. Now I continue to prescribe medication, but I do it differently.

Take 25-year-old Taylor, for instance. She has both anxiety and depression that have at times been crippling, which has affected her relationships, her studies, and the start of her career. She tried several medications a few years ago and didn’t find them helpful. My former self would’ve reached for the prescription pad immediately, thinking, What hasn’t she tried? Were the doses wrong with the ones she did? Did she not take them long enough?

I saw her just last week, so I don’t yet know the outcome of her story, but I can say how my approach is different. I see her anxious depression stemming from a combination of genetics (several others in her family have had similar problems) and a lack of the skills necessary to deal with this degree of emotional reactivity. She didn’t want medication, given her previous experience. I encouraged her not to dismiss the idea altogether, but agreed that we could start with natural, safer therapies. For balancing the serotonin system, we’d begin with diet. Although it’s usually not enough for someone with her history, it may make a significant difference in stage one of recovery, allowing us to focus on prevention.

I also suggested products that combine several nutrients into one capsule. In my experience, they’re helpful at least as often as SSRIs, but aren’t as potent. That’s both good and bad: they can be much more easily tolerated, but may not work for more severe imbalances. I had Taylor start on two products: a serotonin-boosting combination supplement, and a brain-friendly form of magnesium. Depending on how much she’s improved when I see her next, we may give them more time, or we may decide to add a low-dose SSRI.

More Skills, Fewer Pills. I consider the resilience-training part of our clinic to be in the same genre as Dialectical Behavior Therapy, with more of a focus on cultivating resilience for depression. In conjunction, we teach integrative nutrition practices and yoga sequences for each of the mood subtypes, along with basic mindfulness skills, including awareness of breath, thoughts, and emotions. We also teach heart-based practices, like self-compassion, connection with others, and gratitude.

We teach how to be with difficult, painful emotions, how to feel them fully, and how to ground yourself and ride out the storm when emotions are overwhelming. We help people see firsthand how they unconsciously weave their personal story, usually a negative one, into nearly every event in their lives, and how they can start to free themselves from it. And we introduce the ability to listen deeply within and move toward a life of greater authenticity.

At first, knowing how short a time we had with people and how long their histories of depression often were, I was a bit skeptical about whether we’d be able to integrate the skill-building aspect effectively into treatment, but I was surprised by the degree of improvement we saw. Nearly everyone improved, even those who didn’t do much practice outside of the class. Many recovered completely, even without medication. Many others were able to reduce their meds.

I came to realize that people are longing for more skills, and they work. But the single most important healing factor, I believe, is that they learn how to hold themselves differently. They become more self-accepting, more compassionate toward themselves, which leads them to value themselves more and take better care of themselves overall.

Don’t Forget Your Own Self-Care. I almost burned out earlier in my career than most, but I clearly wasn’t alone in how I felt about my work at the time. I didn’t see much joy in my colleagues, either. A recent Mayo Clinic survey bears this out. It found that 54 percent of physicians now show signs of burnout. The reasons for this are complex and include long hours, changing reimbursement, and a sense of loss of control over one’s practice. Also, I believe it reflects a lack of meaning and purpose in the day-to-day work, and I don’t think we’re good at practicing what we preach: we don’t attend well to our own self-care.

I recently met with a young psychiatrist whom I’ve known for a few years. Like me, she’d burned out early and had taken measures to reduce her work hours and stress levels, yet was still feeling burdened by her work. “There’s just so much suffering!” she said. She felt overmatched by the difficulty of working with so much mental illness, and at times she felt distraught about such a disconnect between her genuine desire to be of service and her perception that she’s not having much impact on all the suffering.

It isn’t easy to sustain oneself for a career of service to others. Relieving human suffering from mental and emotional distress is an enormous task and responsibility. None of us can do it alone. We need each other for support and inspiration, continuing to expand our thinking and capacity to do our work in the fullest way possible. When you find your right fit for practicing, and the right place to do it in, you may realize that Thoreau had it right after all. Maybe joy is the condition of life.

Want to earn CE hours for reading this? Take the Networker CE Quiz.

ILLUSTRATION © ROY SCOTT