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Health and Illness: At the Intersection of Psychiatry, Therapy and Wellness
111 Plays3 years ago
In this episode, co-hosts Fara and Grant talk about their experience as psychiatrists who practice therapy. Listen in as we discuss important themes including the difference between treating illness and pursuing personal development, how to balance clinical care with coaching and self-help, and other key considerations in the complex, evolving landscape of wellness and self-care.
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Transcript
Introduction and Mission of Doorknob Comments
00:00:05
Speaker
There's no one field that's trained to cover everything. Hi, thanks for listening to doorknob comments. I'm Farah White. And I'm Grant Brenner. We are psychiatrists on a mission to educate and advocate for mental health and overall wellbeing. In addition to the obvious, we focus on the subtle, often unspoken dimensions of human experience, the so-called doorknob comments people often make just as they are leaving their therapist's office.
00:00:34
Speaker
We seek to dispel misconceptions while offering useful perspectives through open and honest conversation. We hope you enjoy our podcast. Please feel free to reach out to us with questions, comments, and requests.
Integrating Wellness into Psychiatry
00:00:47
Speaker
Hi, today we're going to talk about a very important subject is the intersection of mental health and wellness.
00:00:54
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Traditionally, medicine focuses on disease or pathology, as we call it, although in our training we're taught that prevention is the best medicine and a lot of doctors give important wellness or lifestyle advice, for example, to exercise regularly and eat well.
00:01:11
Speaker
rather than simply take medications if you have a problem like high cholesterol or blood pressure. Within mainstream medicine, there isn't as much room carved out for wellness and personal growth and development. This has been on my mind a lot recently because a company that I co-founded, of which I'm the CEO, has recently launched a membership program so that we can combine psychiatry, therapy, wellness, and wellness coaching and services.
00:01:39
Speaker
That company is called neighborhood psychiatry, but in keeping with fulfilling our mission and moving forward in our mission, we're now using the name neighborhood psychiatry and wellness. This is really not just a name change but it really brings home the philosophical change.
Therapy for Life Enhancement
00:01:57
Speaker
Now, I'm happy to talk about this with Farrah because I know in your private practice, your focus goes well beyond what has become a very narrow definition of psychiatry, seeing patients diagnosing psychiatric problems, giving them medication, and having everything else taken care of by someone else like another therapist. I know you do
00:02:20
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A lot of personal development work, as do a lot of psychiatrists. The other thing I would say about this just by way of prefacing the conversation is that the personal growth and wellness industry is huge.
00:02:35
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it's billions or trillions of dollar industry. And so there's a huge unmet need that people have. And it seems to me to make sense that people who are skilled and well trained should be leading the conversation on how to pull together illness and wellness.
Advantages of Integrated Care Models
00:02:52
Speaker
Yeah, I think that's a very good point. I think a lot of times that traditionally, people would only seek out therapy or psychiatric care if they had
00:03:02
Speaker
you know, some really uncomfortable symptoms or something is going sort of wrong in their life, something that they felt they needed to fix. And I think there's been a shift and maybe it's generational. I'm not, I'm not exactly sure where people just want to make sure that they feel as good as they can feel or that they're getting the most they can out of life or relationships and, you know, wanting professional help to kind of ensure that.
00:03:30
Speaker
And it's hard to find that, I think. A lot of times therapists, myself included, you know, are trained not to quote unquote give advice, for example. And this goes way back to the days of Freud, when the idea of giving people suggestions was considered maybe a misuse of authority. And the idea that
00:03:51
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It's preferable in a lot of ways for people to use insight and figure out what they need, equips them in some ways better. And yet sometimes we know that people need more direction and more expert advice and consultation. This becomes important. I'm thinking about the idea of expertise. And so a lot of different fields are trained well.
00:04:14
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in different areas. But there's no one field that's trained to cover everything.
Beyond Crisis Treatment: Lifestyle and Relationships
00:04:19
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And so if you think about building a model, well, you can have someone who does private practice who offers a great many things. And a lot of people do that. And they're trained very diversely as, for example, you are. They have a variety of skill sets. But when people are looking for treatment within conventional care settings, the model is more of an integrated model where
00:04:42
Speaker
you can go to one place where the people work together and have different people working collaboratively on different parts of issues. I think that probably delivers a really, you know, I think it's possible for the patient to get a good experience either way. I think the problem is when we let illness or pathology
00:05:08
Speaker
dictate all of our decision making without an eye to sort of, we're just playing catch up and trying to put out fires, which is, I think is what a lot of medicine sometimes feels like. We miss these moments where we could make a really big difference, let's say down the line or in the patient's future.
00:05:27
Speaker
Yeah, I agree. You have to know how to shift gears. People often start treatment in crisis. And then later on, you start to see that there's other issues that need to be addressed, which may have precipitated the crisis. It may be the way they're living. It may be a
Differentiating Stress and Disorders
00:05:41
Speaker
relationship that they're in. That's problematic. It may be that they're not happy professionally. It may be that they have an untreated medical or psychiatric problem. But a lot of times, you don't know until the dust settles.
00:05:53
Speaker
Right, or yeah, it may be also that they're having a completely healthy reaction to a difficult moment in their life, you know, and things come up and we're actually getting support around it is a sign, I think of good health and of openness.
00:06:13
Speaker
You know you're saying that there may be reactions to stressors, which there's several stressors that people notoriously have have difficulty dealing with some of them are problematic like loss of a job or relationship problem.
00:06:29
Speaker
Some of them are joyful, like adding a new member to the family, but feeling overloaded. And people's response to stress is normal, right, to a certain extent to have difficulty to have trouble sleeping or to feel worried. And then there's a point where it can go beyond the normal stress reaction and become sort of more problematic. But are you saying there's not necessarily sort of another problem beyond, okay, maybe I just need to
00:06:58
Speaker
work on my coping or how I respond to stress. Exactly. I mean, there might be something underlying, but there also might not be. And I think that it's important to be able to say, well, kind of what's happening to you and what you're feeling while it's negative or sad or overwhelming or whatever it might be is not a sign that there's something that needs to be treated here.
Collaboration Across Disciplines
00:07:25
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And I think that
00:07:27
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for you moving from neighborhood psychiatry to neighborhood psychiatry and wellness, what you're saying is, I guess you're challenging this idea that if you're a psychiatrist and you have an SSRI, right, that's your hammer, everything looks like depression or anxiety, that's the nail. And that model might not be right for everyone.
00:07:51
Speaker
Yeah, that's the traditional biomedical model where you're identifying and treating an illness, which I think is often the case. But a lot of times there's something in the family system. As you're saying, there may be the family has difficulty expressing emotions and supporting one another. Though you could say, well, that's pathological or dysfunctional in the family system. Problem is that people aren't comfortable expressing emotions or seeking help. But that's a different kind of problem than
00:08:21
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you have an abnormality, your body can't produce insulin in the case of diabetes, or even you have a strong biological depression because you have different serotonin genes or NMDA genes or DDNF gene problems.
00:08:43
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We don't really diagnose based on genetic risk factors, but some families, for example, have very high rates of heritability of depression, bipolar disorder, schizophrenia, and that's very different from when there's something in the social system. Yeah, and frankly, it's much rarer. That's why a good history is really important. I think that's what sets psychiatry
00:09:08
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kind of apart from other parts of medicine. We have these longer appointments where we get to know our patients and their families and whether or not something is normal for them or normal for their family system. That's what I always like to say is like, well, you're kind of the authority on you, but it's
00:09:25
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my job to figure out if there's something here that needs to be treated or if you just need a little bit of support or redirection. And it's more than just getting the history. It's also having the background professionally to put it together and make sense of it and understand what the implications are for evaluation and treatment.
00:09:45
Speaker
So one thing that is a little controversial or interdisciplinary issues, you're alluding to it by mentioning psychiatry, like we tend to do this really well. Maybe not everyone is trained that way. On the other hand, there are things that maybe we aren't trained to do that other people do well, family therapy, for example, and very little family therapy training.
00:10:06
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If I wanted to do family therapy,
Training, Boundaries, and Effective Care
00:10:08
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I would get additional training or psychoanalytic training. We had some training in psychoanalytic therapy, but I did four additional years of training in psychoanalysis in order to get good at that kind of therapy. And likewise for other forms of therapy. But you get into a lot of like almost turf wars where instead of people working together,
00:10:29
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they sort of blame and point fingers at each other. So psychiatrists and therapists don't always get along, therapists and coaches don't always get along. And some of it has to do with, I'd say, some kind of shared training, where even if we have different areas of expertise, number one, we understand where the limits are for what we do. Like, so I wouldn't, I wouldn't try to
00:10:52
Speaker
perform surgery on someone, a therapist, maybe isn't in a position to talk about medication choices, though sometimes psychiatrists don't like it if a therapist says, hey, have you thought about this medication, and the psychiatrist says, that's not a good medication for this patient like
00:11:11
Speaker
stay in your lane, right? I see that a lot on Facebook or a coach starts offering therapy but hasn't been trained in how to handle some of the things that might come up in therapy or a therapist gives advice on how to handle something very specific like executive function and maybe they would want to refer to someone trained to help people with executive function coaching.
00:11:35
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Um, maybe, but I have to say, and you probably are not going to like my response to this, but this is not necessarily a problem. That's like just within medicine or within our field. I think in general, because of the availability of resources, specialization, social media, anyone can be.
Trust and Transparency in Therapy
00:12:01
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Okay, maybe not anyone can be a board certified psychiatrist, but anyone can decide they want to learn about psychiatric medications. Anyone, you know, let's say who's in recovery can decide they want to sponsor someone who's new to the program. It's very, very difficult when we try to like tease apart or tell people if the focus is on while stay in your lane, we might not be hearing
00:12:25
Speaker
each other in the right way. Well, that's my point. That closes down interdisciplinary dialogue. And if you have a system in place so that people can work collaboratively and understand the boundaries and the different types of services they offer and work together, that's ideal. And there's a difference between reading a psychopharmacology textbook or blog and having the years of apprenticeship
00:12:52
Speaker
Oh, absolutely. But I think that sometimes people are so narcissistically injured by a suggestion that somebody might make any, maybe it's coming from a therapist, but maybe it's coming from, Hey, you know what? My roommate is on Zoloft and she's doing really well. So can I be on Zoloft too? And then that becomes part of the conversation and part of.
00:13:15
Speaker
you know, while your care is really individualized, and here's why you're not a candidate for this, or I don't, you know, believe you to be. But I have also taken suggestions from patients or from therapists and, you know, found that it worked out really well.
00:13:33
Speaker
Yeah, I think that open mindedness is helpful and the stay in your lane response, regardless of the profession, I think is dysfunctional in general, especially in particularly if you don't know where the other person was coming from. And so I think in general, if unless you know it to be a problem, it's safer to to give people the benefit of the doubt and and it may very well have been
00:13:59
Speaker
like you're saying, like, hey, maybe this will help. I know someone who did really well. It might be better to phrase it in the form of a question with the context. Hey, I know someone who took this new medication.
Collaboration for Patient's Best Interests
00:14:10
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Is the patient we're working with together a candidate for this or no? And that may be more likely to work.
00:14:17
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and that's very different from making a suggestion. Certainly a well-intentioned and possibly valid question may be interpreted as a turf violation when it's not. The main thing for patients to know when it comes to this stuff, because I think people who are very into personal wellness,
00:14:43
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they do a lot of like exploratory work. So they'll try things like acupuncture or life coaching or dating, you know, me with a dating coach. I usually do encourage that kind of thing. I also tell patients, well, I want to speak to anyone who you feel like really understands you so I can get a sense of what that relationship is like because
00:15:07
Speaker
that offers a lot of information about, well, you keep going back to this person or you have a relationship or you feel like this one person is helpful, I wanna know why. Where do you draw the line though? And what are you really after? Because if they told you they met with a friend every week or they spoke with a business mentor every month and they didn't have like a formal relationship, you probably wouldn't say, oh, I'd like to speak with your mentor from the business world.
00:15:37
Speaker
Maybe not, but I usually will say it's helpful for me to speak to someone who you feel like really understands you.
00:15:45
Speaker
knows what's going on here and who would you like that person to be? But one thing is the certification, the training of the people who someone might be working with if they're working with more than one person. And so just like you'd want to know if your physician is well trained or your nurse practitioner is well trained or if they have proper supervision,
00:16:10
Speaker
or what is your therapist doing, you would want to know what a coach's certification is, especially in industries that aren't well regulated yet. And so one of the reasons you might want to speak with someone is also to see what you think of them professionally. Right. In order to serve your patient best, particularly if there's a concern that it might interfere with their care, and at the same time, to stand the best chance of having it serve their care.
00:16:40
Speaker
Right, exactly. Yeah, because I think if people are going to get into conflict, and this has happened very few times with me where I felt like I just couldn't see eye to eye or was gonna be hard to work with a particular outside
00:16:54
Speaker
therapist type. Not just not just a coach, but it also could be a therapist too. If you're not able to practice together, if you have significant differences in the way you think about clinical care, it's going to lead to boundary violations. See also our podcast with Jacob Appel about non-sexual boundary violations. And you have an obligation to put your patient in the middle.
00:17:22
Speaker
Right. And to maybe then take yourself off the case, because then the patient can find, let's say someone, a psychiatrist who's more in alignment with their therapist view of how things should go. So I think it's important. And I think one of the reasons you're saying it's important to connect with other people involved in care, not exactly treatment, right? Because coaches don't treat patients, they have clients, there's professional differences.
Overcoming Fragmented Care with Integration
00:17:53
Speaker
We want to understand the credentials of anyone who we're working with, whether it's a psychiatrist, a nurse practitioner, a therapist, a coach, or an accountant or a lawyer. Do you ever find that people don't understand or push back on giving you consent to talk with these other people? And how do you explain why it might be important to make sure that there's an ecosystem of care
00:18:22
Speaker
where you have access to other people, because a lot of times, and sometimes this is a problem for people, they kind of silo the different parts of their lives. And if they do that with people who are helping them deal with certain issues, sometimes it's also reflective that they do that in work and personal settings. So what do you think about that? Right. I mean, sometimes people are just not comfortable letting their primary care doctor know that they're seeing a psychiatrist usually
00:18:52
Speaker
if they're worried about, let's say me speaking to a parent, I frame it as, well, this is just an opportunity for me to get more information about how to help you. And if the trust isn't there, I don't push it. Frankly, I might say that I can't really do as great of a job as I might otherwise do, because sometimes those conversations yield really, really important tidbits.
00:19:22
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that are going to help the patient. And I also feel like most people know that I would never disclose anything. It's kind of like you have to trust the judgment of the people that you work with not to disclose anything too personal. Just because I have a patient's permission to talk to someone doesn't mean I would ever bring up topics that are not relevant to their work together or something that I feel is private and shameful. But I think it goes along with what is
00:19:52
Speaker
you know, the level of trust in the relationship. The level of trust. And then, you know, what information is necessary? So primary care doctors or coaches don't need to know everything personal. No. But there's some things that they really do need to know. Right. They need to know if we start a new medication. They don't need to necessarily know why we could start something for intrusive thoughts, but they don't need to know what those
00:20:22
Speaker
thoughts are and frankly, I don't know what those other, you know practitioners what their note keeping or security level is like. So I always err on the side of caution and I think most of my patients probably just know that intuitively.
00:20:39
Speaker
in terms of protecting personal health information or personal things. Likewise with documentation. We know nowadays, insurance companies look at notes and patients can look at notes. And so someone who's reviewing the case at the insurance company doesn't need to know very personal details. Right. Right. So I think part of it is how
00:21:07
Speaker
we decide to document and you know the other really big part of it and this is something I think is that's important for patients is that they should always feel comfortable asking about you know what does their chart look like or what are someone's credentials or certifications and anyone who is not really open to that kind of a conversation is probably not someone who's trustworthy. Well
00:21:37
Speaker
That's pretty strong and often maybe is the case, but there may be other reasons why they're not comfortable. It may be a training issue. It may not be whether they're trustworthy or not. You're talking a lot about trust today, which I think is important though. Yeah, because I think it's the foundation of a lot of the work that we do. And there's no reason not to be open about these
Beyond Formal Training: Openness and Skill
00:22:00
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things. Even people that let's say,
00:22:03
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might be, you know, recovery coach with no formal education, other than their own recovery can usually draw on that and be very effective. But if they sort of dance around the question.
00:22:19
Speaker
Then I would I would wonder why, why someone for day pretending to be someone that they're not I do think when we put our. Sorry, what was that i'm just trying to follow what you're saying, what is what is the pretending they're not who's pretending they're. What i'm saying is people should be open about their level their certifications or.
00:22:40
Speaker
level of education because to me it's not the most significant thing. The most significant thing is the trust and the openness and the transparency.
00:22:49
Speaker
Yeah, I think there's a factor, which is how good is the person at what they do? Because formal training is not always reflective of how good a person is at what they do. But I agree, and it's mandated by state regulation that licensed clinicians, or hair cutters for that matter, are required to publicly post their certification.
00:23:19
Speaker
that doesn't guarantee that you're gonna have a good haircut though. True, but it guarantees that they're gonna meet some standard of either cleanliness or, you know. Or that they were at least trained to meet that standard, whether or not they actually meet that standard. They might have the certificate on the wall, but if you see sort of combs laying around covered in like, you know, cut hair, and they're not in that,
00:23:45
Speaker
you know blue thing with the bar beside the bar beside with the comb juice you know you might be like hmm yeah and then you and then nowadays like you're saying before you'll google it you'll be like you're required by law to use bar beside like what's up with that but a lot of people don't ask the questions right whether it's about trust whether it's about training whether it's about skill people are shy to ask yeah and i think that's something right
00:24:12
Speaker
that we look at, right? It might be that it's just part of their nature. It might be that people, you know, react negatively to that when they have questioned others in the past, but maybe their parents wouldn't answer questions and got really mad if they ask. Exactly. Exactly. But I think that's a very good point that we should feel free to ask these questions. And I guess, um,
00:24:37
Speaker
you know, that's, that's a very good starting point. Well, so getting back to where we started this idea of wellness, and mental health and mental wellness, and the need for good interdisciplinary collaboration. Yeah, you know, and what are the goals, right, that people come to treatment for, they may want to treat their depression, but they may also want to like live and flourish more fully.
Aspirations and Personal Growth
00:25:02
Speaker
Mm hmm.
00:25:04
Speaker
And I think whatever those goals are, you know, they should feel like their doctors, their coaches, their therapists are on the same page and on their team and working together. That's how change happens. So I wonder if we're really all trained.
00:25:23
Speaker
to think about it that way. And I think some people will potentially hear a conversation like this and say, that's a first world problem. You have to have a lot already. You have to have a lot of resources. You have to have a lot of privilege. You have to have a lot of basic problems out of the way to be thinking about how to live the well-lived life, to be focused on what Aristotle called eudaimonia.
00:25:51
Speaker
meaningful life through the virtue of living well. Agree, agree. But I think that's something that's sort of aspirational.
00:26:01
Speaker
and what I want actually for all of my patients and the people in my life. I'm thinking, well, when is that a useful idea and when might it make people feel worse? Let's leave that as a question maybe for a follow-up conversation. When does striving for a fuller, richer life, when is the right time to be thinking about that? Is it earlier on, even if there are other stressors?
00:26:29
Speaker
Or will that make people feel worse that that's so far out of reach? Like don't even bring that up. Or is it an idea that you want aspirational, even if you can't make it right? Exactly. Well, very good question. And I think we should certainly do a follow-up where we address that. Very good. All right. Thanks.
Conclusion and Listener Engagement
00:26:52
Speaker
Thank you. Well, thanks for listening. Take care, everyone.
00:26:59
Speaker
Thanks for listening to Dornop Comments. We're committed to bringing you new episodes with great guests. Please take a moment to share your thoughts. We'd love it if you could leave a rating and review on your favorite podcast platform. You can also find us on Instagram at Dornop Comments. Remember, this podcast is for general information purposes only and does not constitute the practice of psychiatry or any other type of medicine. This is not a substitute for professional and individual treatment services and no doctor-patient relationship is formed. If you feel that you may be in crisis, please don't delay in securing mental health treatment. Thank you for listening.