What is holistic psychiatry?
As a psychiatrist trained in the traditional model, I learned a huge amount about psychopharmacology. The practice of identifying and prescribing modern medicines to alleviate distress is central to my work, and we cannot deny the impact that these medications have had for millions of people. Simultaneously, I have known many people who have not found relief from psychiatric medications even after numerous trials of different combinations of medications. I have also witnessed what has felt like inverted logic where it appears that the writers of the Diagnostic and Statistical Manual, the bible of psychiatric diagnosis, have clear financial conflicts of interest.
The human body and mind can be healed in myriad ways. My observation is that the early 21st century American lifestyle is not compatible with good mental health for many people. The features of our lifestyle that cause significant problems are its sedentary nature, the lack of community connection leading to feelings of social isolation, the disruptions to circadian rhythm caused by blue light and evening screen use, lack of sunlight and unhealthy food systems.
Holistic psychiatry seeks to address these issues. It would not be unreasonable to protest that the biopsychosocial assessment that we learn in the context of normal psychiatry training should be considered holistic. I agree wholeheartedly, although I think that holistic psychiatry takes into account the interaction of humans with the natural world as well. The challenge that we are all facing is the extreme monetization of physician time and effort, making it very difficult to practice our craft in a way that upholds the biopsychosocial ideals.
I cringe every time that I hear a psychiatrist referred to as “a provider” or “a medication manager”. As a profession, many of us seek to do more than manage medications, because the human beings who come to us seeking relief from their suffering are more than entities into which medications should be inserted. The offerings of support with and coaching towards a way of life that supports emotional and cognitive thriving are more than managing medications. While there is also psychotherapy, in my practice I additionally look at nutrition and offer support for the ketogenic diet which has shown tremendous promise in treating mental illness. I offer non-sleep deep rest as a way of addressing the intense stress of constantly doing and producing that has become our cultural norm. Psychoeducation around the mental health benefits of sleep and morning sunlight are also an important component of my practice – sleep particularly has been pushed to the margins when it should be a central component of mental health care. And lastly, along with most of my colleagues, I am always looking to make sure that the psychiatric symptoms that bring patients to my office are not caused by vitamin deficiency or other physical health problems.
Practicing in this way takes time. I recall meeting with one startup during my time leading behavioral health at Blue Cross and Blue Shield of North Carolina who gave psychiatrists 30 minutes for a new intake because another party had filled out a form with the “important” information. In training I used to take 50 minutes for a new patient. Now I take 75-90 minutes. It isn’t because I’m getting slower after over a decade doing this work, it’s because I’m getting more interested and realizing over and over again how complex people are. The initial visit is an investment in the healing relationship that pays dividends over the course of clinical treatment. If we take seriously our charge to heal our fellow humans, we cannot rush that process.
Lastly, whole human medicine requires us to break the rules. I began seeing a patient who was afraid to come to clinic, so I started doing home visits with he and his guardian. This isn’t rocket science and physicians have been doing it since the beginning of our practice. But I have a close friend who wants to have home visits for some of her patients and isn’t allowed to do so by the corporate practice for which she works. I get it – the malpractice insurance might not cover it, and the physician time is expensive. But what is more expensive is not being able to meet people where they are with the goal of alleviating suffering. What is more expensive is the culture that we create by consistently putting profits before people. We are so deep in a profit-driven culture of medicine that it has become hard to recognize what is possible when we start meeting people where they are, listening deeply, and thinking creatively about healing. Ultimately this is why most of us became doctors in the first place.