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Recovering the Soul of Psychiatry: A Conversation with Johns Hopkins’s Dr. Margaret Chisolm

“I want to give people hope, people living with mental illness as well as family members of people living with mental illness, that not only can they survive their illness, but they can also reach their greatest potential. Sometimes, in fact, they reach their greatest potential not despite the illness, but because of the illness.”

In the latest installment of our interview series, Public Discourse Editor-at-Large Serena Sigillito talks with Dr. Margaret Chisolm about her new book, From Survive to Thrive: Living Your Best Life with Mental Illness. Rejecting both mechanized disease reasoning and pure emotivism, Dr. Chisolm advocates a more holistic psychiatric approach—one that emphasizes the multidimensional quality of mental illness and the need to encounter patients as human beings, existing within relationships and communities, who can learn how to build a flourishing life.

Dr. Chisolm is Professor, Vice Chair for Education, and Director of the Paul McHugh Program for Human Flourishing, all within the department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine. She has a secondary appointment in the department of Medicine. Board-certified in general psychiatry and addiction medicine, she has over three decades of clinical experience in both general and specialized psychiatric outpatient and inpatient settings.

Serena Sigillito: I recently read and really enjoyed your new book. Could you tell our readers a little bit about it?

Margaret Chisolm: Sure. The idea of the book had been brewing for a long time, because I trained at Hopkins in the late eighties, early nineties, and then had a private practice for many years, and still see patients now through my work at Hopkins. And the first question that patients always ask is “What kind of psychiatrist are you?” You know, “What approach do you use? Are you a psychoanalyst? Or a biological psychiatrist? What’s your theoretical background?” And it takes a while to explain the perspectives approach.

The perspectives of psychiatry is an approach to thinking about patients who present with psychiatric problems. And it’s a way of teaching people to think about psychiatric problems. Dr. Paul McHugh (who was the chair in our department for at least thirty years, starting in the mid-seventies) along with Phillip Slavney (who was the residency director when I trained) developed this approach. Dr. McHugh thought to himself, “What does the field of psychiatry really need?” And he thought that it needed a way of organizing psychiatric problems according to their inherent nature. So he and Phillip Slavney wrote a book in which they articulated this approach, which really was just making explicit what psychiatrists did and what they knew implicitly: namely, that not all psychiatric problems are similar in their origins.  Some may be due to something that somebody has, a disease that’s come upon them, like schizophrenia or mania. Some might be a reflection of who a person is—their cognitive capacities, their personalities, their affective temperament—such as a cognitive disability or personality disorder. Some psychiatric problems emerge because of what somebody is doing, like restricting their food intake or using substances. And other psychiatric problems have their origin in something that a person has encountered, like grief or post-traumatic stress disorder. Obviously, some problems cross over those boundaries. It’s not an “either/or,” it can be sort of an “and/or” way of thinking about psychiatric problems.

 

That’s a lot to explain to a patient. So the reason that I wrote the book, and why I’ve been thinking about the book for a long time, was that I thought it would be a helpful resource to have, not only for my own patients but for anybody who has a psychiatric problem or has a family member with a psychiatric problem . . . which is pretty much everybody! I thought it would be important to explain what I think is a really sensible and evidence-based way of thinking about the nature of psychiatric problems. It’s not a widely used or taught approach outside of Hopkins, although hundreds of papers have been written about it. And people who have trained at Hopkins have gone other places and have imported the approach to other places, but it’s not part of sort of mainstream psychiatry, like the Diagnostic and Statistical Manual is. So that was my initial reason that I thought about writing the book.

Then, in 2015, I joined the Paul McHugh Program for Human Flourishing, which was created that year. And I got interested in the relevance of the concept of flourishing to all patients, not just patients with psychiatric problems. I realized that what Tyler VanderWeele is proposing in his flourishing model, in terms of the pathways of flourishing and the domains of flourishing, were things that we were certainly aware of at Hopkins. We had already incorporated it into our approach of taking a history and evaluating patients. We were always very interested in what their connections with family were like, what their connections to communities, including faith communities, were like, what their work background was, what their educational background was. Those are all aspects of the history that we would include in our initial evaluation of a patient, and that we would also think about in terms of developing plans for patients. Because our goal is not just to get somebody better from their acute psychiatric illness, but to actually keep them well, and help them reach their fullest potential in life. The flourishing model really resonated with our approach to psychiatry at Hopkins. So then I thought, in addition to writing a book that explains the perspectives of psychiatry, I’d also include in the book some of the ideas from the flourishing model proposed by Tyler VanderWeele, because those are obviously also relevant to our patients.

That’s the main goal of the book: to present the perspectives approach and to present the flourishing model and its relevance to all of health, including mental health. I want to give people hope, people living with mental illness as well as family members of people living with mental illness, that not only can they survive their illness, but they can also reach their greatest potential. Sometimes, in fact, they reach their greatest potential not despite the illness, but because of the illness.

SS: I’m thinking about our Public Discourse audience and how they might react to the idea of your book. My sense is that a lot of our authors, and probably a lot of our readers, tend to distrust contemporary psychological and psychiatric frameworks. I think about Philip Rieff, and his idea of the therapeutic replacing faith. If someone said to you, “I understand virtue ethics, and I have faith. What is the use of this psychological mumbo jumbo? What does this contemporary framework add to that?” how would you explain the unique contributions of what you’re presenting?

MC: I guess I would say that what I’m presenting, both the perspectives approach and the flourishing model, these are based in scientific evidence: biomedical evidence for the disease aspect of the perspectives, epidemiologic evidence for the flourishing pathways, and then psychological evidence for the other three perspectives (the dimensional perspective, which is about personality, the behavioral perspective, and the life story perspective).

What Rieff talks about is that we’re living in an age of feeling. One thing I want to really clarify is that the domain of psychiatry is mental life and when it goes awry—and by mental life, we mean thoughts, feelings, and behaviors.  The idea that psychiatry is all about feelings, and your feelings are everything, is a popular misconception. People have feelings, no doubt. And our feelings pretty much come naturally. They’re out of our control. What is in our control are our thoughts and our behaviors.

So, as psychiatrists, we’re certainly interested in understanding what someone’s feelings are, but we don’t see our job as validating feelings or dismissing feelings. Our job is to help people live the fullest life possible. And we know from taking care of people who have “two scoops of feelings,” as my colleague Glenn Treisman says, that strong feelings can often get in the way of someone’s functioning and reaching their greatest potential. In psychiatry, yes, we’re concerned about the realm of feelings, but we’re equally concerned about thoughts and behaviors.

 

We think it’s important for people to have goals, and to realize that life’s a series of many decisions. Every day is a series of many decisions. And those decisions are either going to lead you closer to your goals or further away from your goals. If your goal is to lead a good life, to flourish—and by flourishing, I mean to be happy, to have satisfaction with your life, to have good physical health, mental health, meaning and purpose, character and virtue, and close social relationships—you can see how the decisions that you make can lead you closer or further away from your goals. It is important for people to be able to have agency in their life and to realize that sometimes your feelings can be problematic, in that they keep you from reaching your goals. Our job is not only to help you process those feelings but also to counter those feelings with thoughts and behaviors that are going to be more adaptive for you. So I don’t see that in conflict with ideas of moral agency at all.

I’m not an expert in philosophy, but I certainly do see the problems that have arisen in our society and culture because we have made feelings the most important thing in our lives. Obviously, feelings are important to us as human beings—they’re part of our life—but our thoughts and our actions are equally important.

SS: I really appreciate the balance that you strike: understanding the importance of individual agency in confronting these problems but not seeing the individual as totally self-constituting or only focusing on a person’s feelings. In the framework of human flourishing, you really emphasize the importance of external work and community in particular.

Near the beginning of the book, I was really struck by your description of the very thorough process you use to assess your patients. You note that you like to talk to family members or close friends as part of that process. I think that’s something that’s missing in a lot of psychiatric treatment today. If you think of the treatment of gender dysphoria, for example, especially as it relates to children who identify as transgender, there’s such a privileging of the individual’s self-reporting. There’s no sense of the parent as someone who should be consulted in order to really understand what’s going on. But sometimes, even as adults, and even in the absence of mental illness, we’re not reliable narrators of ourselves.

MC: People can have psychiatric diseases that totally distort their thinking. If you’re depressed, sometimes you can think you’re a terrible person, and you’ve always been a terrible person. If you’re actively using substances, you can have distorted thoughts about your essential character, because substance use can erode your character. Behavioral disorders in general, but substance use in particular, can erode your character. You might not even remember what kind of person you were before you started using. Or somebody starving themselves with anorexia nervosa can have very distorted perceptions about themselves, because starvation affects the brain. Even our personalities, in the absence of mental illness, can influence our thinking. If we’re putting more emphasis on feelings than on thoughts or behaviors, that can distort our recollection our retelling of our story.

In general, the meaning that we give things can be idiosyncratic. We can give a meaningful explanation for something that makes sense, but has little causal evidence. So I think it’s really critical to get the family members’ perspective. First of all, they’ve known the person a long time. They have that longitudinal perspective. But people are funny, you know, in the things that we choose to remember. The things that we highlight can be very distorted.

I often give the example of my son, who talks about himself as being “a sickly child.” I was like, “Why would you think you were a sickly child? Other than your well baby visits, you only had one visit to a pediatrician with one ear infection! You missed one day of school. I can show you all your attendance records! Other than that, you never missed a day of school.” But he had one memory of vomiting from a bunk bed—which, I can assure you, was quite dramatic. And it had distorted his memory. People are funny like that. And so, I would hate for him to be seeing a doctor, and having them take a history, and giving his perception, which . . . I mean, look, I understand that that is your perception, but there are some real ways that we can reality check that.

Somebody can say that all their problems are because of their wife or their husband. And that’s the meaningful explanation they’re giving themselves for having their marriage fall apart, or having lost their job, or whatever. But, actually, if you talk to the spouse, they can say, “No, this person was depressed, and they were really irritable. And we were having a lot of fights.” And it was the depression that came first. It’s not the marital discord that was driving the depression, it was the depression that was driving the marital discord. So there can be problems in your life that you attribute to one thing, and it makes sense, but it’s not really causal.

We fall into a trap as psychiatrists if we always take at face value the meaningful explanation that patients give us. I have a patient now that I’ve been seeing for thirty years, and he gave me permission to share the story of the time when he was in therapy for six months with a therapist, because he believed that he had had an affair. He was talking to this therapist about this affair that he had, trying to process it all. And finally, his wife got to talk to the therapist to say, “Look, we work together. We live together. He has never had an affair!” And it turns out that this was all delusional. He was in a psychotic depression, and had wasted all this time in therapy, and he was getting more and more severely depressed. He ended up getting into treatment, getting a biological treatment for depression, and getting better. And that belief went away completely. But if the family member hadn’t inserted herself into the treatment—she wasn’t invited into the treatment, she had to insert herself . . . if they had known that from the beginning, it would have saved a lot of suffering. He would have gotten help sooner.

So I think it’s really critical. Because again, things can sound very plausible. They can sound like great explanations for your problems, but they aren’t necessarily causal. And you really need to do a full evaluation to try to figure out, “What is the cause of the problem that you’re bringing us?” You know, is it because you have a disease? Is it because of who you are as a person? Is it because of what you’re doing? Is it because of this story that you’re telling yourself?

SS: You shared in the book your own story of experiencing postpartum depression, as well as the story of your brother battling addiction and eventually succumbing to suicide. Obviously, those are extremely personal and sensitive stories to share, and I think they make the book really engaging and relatable. But, as you know, there’s a lot of social stigma around mental illness.

How did you decide to share your story? Was that something that you shared openly pretty soon after the fact? Or is this something only more recently that you’ve felt comfortable talking about publicly? Because it seems like there’s been a big shift in recent decades in attitudes about mental health.

MC: One of my goals of the book was to demystify psychiatry and psychiatric problems. The other big goal of the book was to destigmatize.

When I have taught the perspectives of psychiatry in the past, I have used case histories of famous people to illustrate the various perspectives. Like Ernest Hemingway’s life: how much of his psychiatric problems could be attributed to disease, how much could be attributed to his personality, how much could be attributed to his life experiences—he had a lot of injuries and had chronic pain—and how much could be attributed to behaviors? Obviously, he had a major drinking problem. So he’s a great person to illustrate all four perspectives. So I would often use his case.

I knew I wanted in the book a longitudinal thread of somebody who people respected who had had a psychiatric problem. I wanted to use that to illustrate the perspectives. But, frankly, it was going to take a lot of work to do the research for a book on Ernest Hemingway’s life. I’m not an Ernest Hemingway scholar! So I thought, “Well, I know my own life experience. I don’t have to spend months in the library and archives.” And I thought, it also helps the goal of destigmatization, too.

Many people close to me didn’t know, and they have commented since the book came out that they didn’t know the story. I would talk about it. I wasn’t shy of talking about it, but it’s one of those things that doesn’t always come up. I typically don’t talk about it with patients, because patients and their problems should be the center of attention. I rarely talked about it with psychiatric learners, because I don’t want my teaching to be all about me either. But I thought in this case, it would help the book to have a story that readers could follow through the book to illustrate the points, as well as kind of helping connect me to the reader, while also serving the goal of destigmatization.

SS: At the beginning of our conversation, you were talking about how difficult it is to explain this perspectives framework, and how in most places it is not the standard of care. If someone is looking for good psychiatric care, how should they go about finding it? How can they know if their psychiatrist is using this approach?

MC: I’ve actually asked the Department of Psychiatry to develop a website to help with this. We’ve been rated number one in the country for the last couple of years by US News and World Report. We’re obviously well-respected, and we have limited capacity to see patients ourselves, but we’ve trained hundreds if not thousands of psychiatrists in this method. So finally, we have a website that’s organized state by state to help you find a Hopkins-trained psychiatrist. And everybody that’s trained at Hopkins since the mid-seventies has been trained with this method.

SS: It seems like such a rich and helpful framework. And yet it hasn’t made inroads at other institutions?

MC: It has at some, but not a lot. The Diagnostic and Statistical Manual, the DSM, pretty much reigns supreme in psychiatry, and has reduced psychiatry to something that’s actually quite boring, which is just looking for a checklist of symptoms. If you meet all the symptoms on this checklist, then you’ve got this disorder. The way that the DSM is organized implies disease reasoning.

Disease reasoning starts with a clinical syndrome, which is a cluster of signs and symptoms that run a course together. And that’s how the DSM is organized: by signs and symptoms and categories, rather than thinking about somebody dimensionally in terms of their personality, or in terms of their life story.  The latest version of DSM has “prolonged grief disorder” as a diagnosis. It’s just absurd. They’re taking the problems of being a human and medicalizing them, pathologizing them.

The DSM was initially developed as a research tool for reliability purposes, to help somebody, say, in the UK who was researching schizophrenia and somebody in the US who was researching schizophrenia to make sure they were researching the same clinical syndrome. There’s no test for schizophrenia that you can give. All you can go by are these signs and symptoms. And so they just wanted to make sure that the signs and symptoms you were going by were the same as the ones used by researchers someplace else. So it was all about reliability.

 

But that’s really broken down now. Even the field trials for DSM5 for the reliability of major depression diagnosis showed low reliability. So it’s not even that useful for reliability purposes now. But it’s used for billing. The American Psychiatric Association publishes it. They come out with a new edition every seven years. It’s a political process, deciding what goes in and what comes out, and they make a ton of money from the sales of the DSM. It’s an industry unto itself.

It’s hard to compete with something like that. It’s quick, it’s simple, it’s too good to be true. And it’s not. I mean, this takes time. A psychiatric evaluation where you’re talking to other family members, and you’re spending an hour or two asking a lot of questions about somebody’s growing up years, and their family of origin, and their life experiences . . . that takes a lot of time. But I think it’s time well spent, because you will avert unnecessary, or even harmful, treatments.

SS: Your approach also seems much more relationship-based—a human encountering a human and helping them heal, versus a mechanistic vision of, like, “there’s something broken, and I have to fix it, and then move you along.”

MC: Yeah, I mean, the rest of medicine could benefit from thinking about some of these aspects of being a human as well. I really think the human caring side of medicine is challenged right now. It’s behind a lot of the problems we’re having now with vaccine hesitancy and all that, because trust is eroded. We don’t trust our physicians in the way that we used to. But with psychiatry, your mental life and your sense of self are so intertwined, that you have to recognize the person as a person with hopes and dreams and goals. Even if the main thing you’re treating them for is a psychiatric disease, that has meaning in their life. They give that meaning. And it affects their dreams for themselves. And you’ve got to deal with that. It might make them question their value as a human being to have such an illness.

I was reading after the book was published, actually, this paper that came out about people with schizophrenia. This paper is about three domains of recovery. One domain is symptom recovery. Another domain is functional recovery. And the third domain is personal recovery. And by personal recovery, they mean that you feel valued as a human being, you feel like your life has meaning and purpose. These researchers found that in a third of people who had active symptoms of schizophrenia—they were still hallucinating, or still delusional or still had thought disorders, and they had no functional recovery, no symptom recovery—a third of those people were able to have personal recovery. So they were able to see that their lives still had value, that they were still worthwhile persons, with a sense of meaning and purpose.

If somebody with active symptoms of schizophrenia and no ability to function can feel like their life is meaningful and purposeful, then we as psychiatrists can and should play a role in helping people gain that sense of personal recovery. We’ve been too focused on symptom recovery and functional recovery. Not that those aren’t goods. They’re very good things to have. But even when you can’t get those, you can still help people have personal recovery.

SS: It makes me think too about the place of suffering in human life and its relationship to meaning. We’ve alleviated so much material suffering. But then, particularly since the pandemic, in our society, there are so many problems with depression and anxiety, so many people who are tormented by a sense of meaninglessness.

MC: I think this is so important. When I give talks to people outside of psychiatry about flourishing, I’ll say, “Look, doctors are always complaining about their patients who aren’t doing what they say. They’re not taking their diabetes medication or whatever. But think about this patient who is not taking their diabetes medication, they’re not taking their insulin. If you asked about their family, work, education, their community, if you asked about the domains of flourishing, you might find that this person isn’t happy, has no satisfaction in their life, has mental health problems, has no sense of meaning or purpose, has no close social relationships. Why would they take their insulin? Why would they want to prolong their life?”

That’s why this is so relevant to all of healthcare. I think we have to have an understanding of a person, a whole understanding of a person, to be able to help them not only get over their physical health problems, but to sustain their well-being and actually flourish. The only place I see this in medicine today is in addiction. It’s very common for addiction treatment programs to say “You need to have a job. You need to be part of AA or NA. You need to rejoin your faith community.” I think it’s only because we’re so desperate in addiction. It can be so challenging that we start being much more prescriptive. And we start saying, “You’ve got to make amends to your family, you have to get a job, you’ve got to go back to school, you’ve got to reconnect with community of people who aren’t using drugs. And if you have a faith, seek that out.” People in addiction treatment don’t give that a second thought. That’s part of recovery. Because we know that if people don’t do that, they’re going to relapse.

In the rest of medicine, people are very afraid of making prescriptions in the domains of family, work, education, and community. But I think it’s just as relevant. Because if somebody has no reason to take their insulin, because they’re living a miserable, isolated life where nobody depends on them, where they have no responsibilities to anybody else, and nobody has responsibilities to them, then it’s going be hard to convince them to do things that prolong their life or enrich their life physically.

Image Credit: Greg Dohler Photography

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