Psychiatry & Psychotherapy Podcast - From Survive to Thrive with Margaret Chisolm, M.D.

Episode Date: January 11, 2022

In this episode, we will be discussing, From Survive to Thrive, a new book by John Hopkins' professor and author, Dr. Margaret Chisolm. In her book, she outlines the four perspectives of psychiatry that are the standard approach used at Johns Hopkins when assessing patients. Problems are considered from each of these perspectives.  It is about discovering the origin of a patient's problems and using that as a guide for treatment. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is emailed to you in seconds.

All right, welcome back to the podcast. I am joined today with Meg Chishon. She is the vice chair of education and a professor of psychiatry and behavioral sciences at Johns Hopkins. She has recently written a book that we will be talking about today called From Survive to Thrive, Living Your Best Life with Mental Illness. That is her only conflict of interest. It's a book written for patients, so that would be considered a conflict of interest. She has no other conflicts of interest. and we will be talking about this book.

We will be talking about it's a book that's written for people struggling with mental illness by an expert psychiatrist who has also struggled with mental illness and had family struggles with mental illness. And so this is the second book. Her first book was talking about perspectives of psychiatry. It's an approach that was born out of the Johns Hopkins. psychiatry department. And she's co-authored some articles on this, some scientific articles.

So this book seems to be kind of like, like now we're taking it to the patient and helping them understand how the perspectives approach to psychiatry works. So maybe can you start off by talking about the perspectives approach to psychiatry? Yeah, what is the perspectives approach? That's a question I get all the time from patients because patients come to be and they say, hey, what's your theoretical approach? Are you a psychoanalyst? Are you a biological psychiatrist? And I say, okay, I take a deep breath and say, well, at Hopkins, everybody is trained in the perspectives approach, which means that we look at each patient from four perspectives and consider

the problems that you're bringing to us from those four perspectives. It's a visual analogy. It's like, you know, you're looking at people from different angles. And the four Four perspectives are, well, let me back up. So we're looking at people from four perspectives, and we're asking whether or not the problems they bring us are arising because of something the person has, like a disease. So disease is one of the perspectives. Are the problems arising from who the person is, their personality?

That's the dimensional perspective. Are the problems arising because? of something the person is doing, that's the behavioral perspective, or are the problems, or I should say and or are the problems arising from something the person has encountered? And that is the life story perspective. So the four perspectives are disease, dimensional, which is about personality, behavior, which is about substance use, eating disorders, behavioral disorders. and the life story perspective, which is this personal perspective about the meaning that you're giving events in your life.

So that's why I wrote the book, because it takes a lot to explain that. And I'm sure, you know, when you go to the doctor, you don't remember half the things that doctor tells you by the time you're out the door. So I wanted to give patients a book to help them understand how we approach psychiatry and also people that aren't able to see. somebody here at Hopkins, it would be helpful for them to understand this approach. We have been, for the last couple of years, rated as the number one psychiatry department in the country by the U.S. News and World Report. So we do think we're doing something right. And what we're doing is using this approach as a framework for understanding how to think about the origin of patients' problems and then use that same framework as a way of guiding treatment. Wonderful. Yeah.

Yeah, so as I was reading your book, I have on my bookshelf a, I think it was the original sort of textbooks, textbook of prospective psychiatry. And I was reading your book and I was thinking to myself, oh, this is like kind of how I talk in the podcast. You know, we do a lot of episodes on personality. I did a big series on the Big Five where we spent like one to two episodes on each of the Big Five. Oh, that's great. Looked at the hardcore research. I use the Neo PR on patients quite frequently in coaching clients, which is the gold standard. It's like the 40-minute, 50-minute test.

And so I was like thinking about you, as I'm reading this book and I'm like, she's definitely high conscientious, high order, high structure, high achievements driving, right? Yeah, it's not good or bad. It just all depends on the situation, right? That's the great thing about these dimensions, the big five, is that, you know, it's all context dependent as to whether it works for you or doesn't work for you. Yeah. No, absolutely. I mean, it's like personality.

You also share in the book how your high neuroticism. So high stress reactivity, right? Which I'm like reading through this and I'm like, well, I don't know. you're doing so much in your life. It's like, of course you're going to get to these points where you're like feeling cumulative stress, you know, or you're like that conscientious is kind of driving you forward. So I had some empathy for you there. Well, you know, the funny thing about neuroticism is it's a very internal experience.

People tell me all the time, if I get feedback, I'd say 50% of the time people will say, you seem so calm. So, I mean, I can be, I can appear very calm on the outside, but inside I'm, you know, worried about a bunch of things thinking about things I just said or things I'm about to do. So just goes to show you that neuroticism is a very internal experience. And you really have to ask specific questions to try to bring that out because it's not obvious on, you know, in terms of somebody's appearance. whether they're neurotic or not.

Right. I think it's a very helpful way of understanding things. I'm going to do an episode where we talk about temperament and how temperament can be identified even in the first couple hours of life. Yes, it can. That's for sure. Yeah. So it's like I think there's one of the errors I see is that a lot of people, when they only

have one domain to think about, you know, like trauma, not trauma. You know, it's like everyone is, has a history of trauma. What if they're just more wired in a neurotic fashion? It's like you're never going to completely uncover all the trauma that would lead to a resolution, and you can continue to look for it. But then what if you look for it and it's not there

and your therapist kind of like wants it to be there? You know, that's what I've seen some. Oh, yeah, definitely. I mean, actually trauma is a really interesting topic because I tend to avoid the use of it. of the term traumatic event or something like that because an event and how you process it is really so dependent on your temperament. I mean, I think about 9-11. And I once had a patient who was in New York in one of the lower world trade center buildings on 9-11. He never lost a night

of sleep. Oh. Because of his temperament. He had a very non-neurotic. of, you know, non-emotionally reactive temperament. Meanwhile, there are people halfway across the world who aren't able to sleep. And so he didn't perceive that as a traumatic event, but people halfway across the world did. And I would say, you know, the difference was not their, obviously their proximity to the event, but was their temperament. Right. So what you're, you're, I think, important, the important thing of what you're talking about right here to me is that your empathy for him is meeting him where he's at,

not where you suspect that he's going to be at, right? So your temperament is very different than his, and this is where I think we can have blind spots as clinicians and therapists. It's like, you know, do we see everyone with our own lens? Do we see everyone with our own intelligence? You talk about IQ as well, being kind of one of those important, is it in the domain of personality you would put IQ? Yeah, it's part of, yeah, affective temperament and cognitive capabilities, both come under personality. So, yeah, it's so important to kind of like see what is in the person that's presenting. And do they experience the stress in the way that we might imagine or maybe they're not?

Maybe it's like... Really important. Something totally different. Yeah, such an important point because. The way we frame this is, you know, there's observations and then there's interpretations. And so often somebody will, a clinician, will think, well, if that, for me, this is how I would react. And so they assume that the patient is reacting that way. And then when you ask, well, what evidence do you have?

You know, the patient has told you they're not, they aren't feeling upset. They don't look upset. why do you think they are upset? Then they realize, oh, it's because I would be upset if I were in that situation. So I think it's really important to distinguish what's our interpretations and what are our observations. Because we all have biases. And psychiatry, of course, we're relying so much on trying to understand the mental life or the mental experience of someone else. that we don't have tests for and we don't have as many objective measures for.

So we're more prone, I think, to being biased in our interpretations. Yeah. So personality, okay, so your high conscientiousness, high neuroticism, I would put agreeableness as like middle of the road or high, what would you put? For me? Yeah. Oh, I was surprised. I was actually a little disagreeable, which really was a surprise to me.

And that's been consistent over time. I've retaken this test. But I think I'm not as flexible. So I think it's that sort of that factor of flexibility. Like, you know, okay, we have plans to do something tomorrow. And now you're telling me that, you know, you're asking, can we change those? And my first impulse is to say no. See, but I would put that as your conscientiousness.

It is part of conscientiousness. It's like that conscientious, you like to have a plan, you like to execute the plan. It's hard. But I'm a little rigid. I'm a little rigid and inflexible. But that's conscious. I would put that consciousness. This is my, or my take.

Like my take on things. It could be. But you're saying maybe middle of the road, I would be, I would wonder if you would be comparing that to gender norms or not, right? because some of these tests are you compared. Oh, yeah, definitely. Oh, don't tell me about that. When I took, I don't know how old I was. I think it was 18 when I took the MMPI. Okay. And, of course, the only thing I scored abnormal on was the masculine feminine kind of scale. I don't remember what it's called.

Because I was endorsing things like, would you rather be a doctor or nurse? I'd rather be a doctor or whatever. There was a huge bias in that scale. Yeah. The way they did that back then was like, It was, yeah, it was, but as an 18-year-old girl, I didn't want to be, you know, pointed, I didn't want to point it out to me that I was high on the masculinity scale. That's not what I wanted, you know, an 18-year-old girl once. Yeah. Yeah.

Yeah. Okay. So, and then extroversion, introversion. And I think you said introversion, right? So it's like, and I could see that in how you are, like, your ideas are very thought out. It seems like you've, you've written out these thoughts after you've thought about them a lot, whereas sometimes with the extraversion, it's almost like it's coming more. Yeah, right. I definitely edit before I speak or write.

Yeah. Self-edit. Yeah. Okay. And then what's the fourth, there's the fifth, a personality type. Let's see. Openness. Openness. Yeah. Okay. I would, uh, yeah. I'm very open. I'm very open. Okay. Okay. Yeah. Which interestingly, a lot of my listeners, whoever reached out to me and want me to score them, they're all very open. And so I wonder if I self-select those people by how I do the episodes and how it's a lot of ideas and I leave. I don't often give concrete, like, therefore, this, you know? It's kind of like, here's the data. You interpret it, you know? Yeah, I do think, you know, I think people who are psychologically minded tend to be more open. I mean, it's an, these are abstract concepts we're talking.

about. Right. Yep. There are no right or wrong answers often. You have to tolerate a lot of ambiguity. People like that. Psychiatrists tend to embrace that a little bit, yeah, in general therapists as well. Yeah, okay. So you have... But you know, interestingly, openness is the temperament dimension that is most predictive of doing well as a patient in psychotherapy. If you're more open you are. because you want to be curious about yourself, right? Right, yeah. Some people aren't that curious if they're very low on openness, surprisingly. Right, yeah.

I've a couple images of patients come to my mind who scored very low openness and, you know, they could come to the end of therapy and not value what was done even sometimes because it's like it's easier to think there's a bone, it was broken, now it's fixed. It's harder to think, like, I had some narratives in my life that were giving me chronic stress, the way I was looking at things, the meanings I was attaching to things. And after working through that, I don't have this chronic stress anymore. It's harder to sort of grapple with that reality than, like, I had this bone and it was broken and I was fixed, you know. Definitely more abstract.

Yeah. Okay, so the four perspectives. Personality, disease, something they have. Can you give me some examples of disease? Yeah, so the disease is what we're used to in the rest of medicine for the most part, which is there's a broken part or function in the body or in our case, usually in the brain. So it's things like schizophrenia. This comes upon you unbidden.

You haven't done anything to make yourself more likely to have schizophrenia. It comes out of the blue. It is stereotypic around the world. It pretty much looks the same. You know, the kind of special features of your hallucinations or your delusions may be idiosyncratic to you, but the fact that there are hallucinations and are delusions that are associated with schizophrenia makes it seem very much like a disease, like other diseases, that something has gone awry, something has, you know, something in your brain functioning or structure. has developed differently and you have these symptoms that you can't really control. Yeah, I think about disease. I think about like diabetes, heart disease as well, like these things that influence mood that play a role in pathology, dementia. Would you consider that? Yeah, dementia, acquired brain injury. You know, I would say manic depressive illness, people who have beer cut manias, there's not a really good explanation for that.

I mean, with depression, there's a little more variability in terms of what the origin of that is. But with mania, you know, if you wake up one day and, well, actually, if you never go to sleep that night and are cleaning your apartment all night long and starting to think that you're, you know, a religious figure, it's, hard. That's a qualitatively different experience than most people have. Yeah. So disease, okay, so you have personality, the dimensional, you have disease, something they have, and then you have doing, which is like behavior, substances. Yeah, I think behavior is really interesting because there's because you know in order to survive as a species there are certain behaviors that we need to engage in like sex and to get to the point of puberty and reproductive viability you have to have survive by eating and feeding yourself and sleeping so there are these

innate drives that we have to engage in behaviors so the brain circuitry is already there to support, you know, us having an appetite for food. And then when we eat, we get satiated, but then our appetite grows again. And we might have, you know, we might find that we like a certain kind of food. And so we get conditioned to eat more of that. And then we might choose to eat less of one kind of food and more of another based on that conditioning. So that's all supported by brain, you know, circuitry. And then we might get exposed to something that doesn't, that we don't need to survive for ourselves or as a species like alcohol. And we might find then we develop a taste for alcohol, much like we have taste for certain foods. And we get conditioned to enjoy that. And then

we don't have the alcohol, we don't feel well. We might start getting shaky if we're drinking regularly. And then, you know, we have more of a drive, more craving to use the alcohol. And then our ability to choose not to use the alcohol diminishes and narrows. So that's really different from the disease of schizophrenia because there is this element of choice, even though obviously it gets very narrowed with conditioning and drive. But still it is different from something that just comes upon you unbidden. And interestingly enough, substance use disorders, like alcohol use disorder,

they actually have a lot in common with things like eating disorders or sexual disorders, where there is, again, this choice, this condition learning, and this drive cycle. So yeah, those words are there for reason. Choice. You know, we have both choices to change our environment. We have choices that we can choose to not believe in free will, right? There are some people who don't believe that they have a choice. I did three episodes on free will. And one of the things I found was that continually there was positive, psychological things that came from believing that they had a choice. And all sorts of economic games, whenever they tried to convince people that they didn't have a choice, they had like decreased, you know, good things. Yeah.

I mean, that's why agency is so important in psychotherapy, trying to develop a sense of agency that you do have some control over things in your life. Yeah, I was just talking to a coaching client, last night and this guy he's got like an eating disorder you know 50 7 inch waist and interestingly as he talked about food he said he started to talk about it as if it was something he didn't have any control over you know and so there's there's a belief there's a story right where he doesn't feel like there's this domain anymore where there is choice. You talk a little bit about the book in the book about how you yourself struggled at some points with like losing weight and stuff. How would you,

like, what is the, is this part of your approach, kind of the doing, finding choice, finding agency? Oh, definitely. Yeah, I lost, I think something like, I don't know what it was, 65 pounds of some crazy amount. You know, and I did that intentionally. Actually, one of my patients has a severe mental illness was able to lose weight. And I thought, well, my gosh, I should be able to also. So I made a conscious commitment. And really, that's what it is with all behavioral disorders, right? With people with anorexia, with people with alcohol use disorder, at some point, it comes down to you making a commitment to change, basically. And, you know, that's all about readiness to change. Well, I was ready to change.

I was starting to have health effects. I was right on the line between overweight and obese. And I was like, I'm not going there. And so I enlisted the help of a weight management center at Hopkins and got weighed every week. So there was accountability, just like there is in, say, AA or NA where you're going to daily meetings. and it was clear if I wasn't sticking with the program.

And I got support. So I was getting and I was obviously, you know, seeing on the scale that I was losing weight. So there was conditioning that was positive. And then my drive to eat actually decreased as I ate the foods that they were prescribing. And it was like medicine. That would be prescribed really. It wasn't quite real food. And then, you know, it became easier to choose, you know, not to eat the foods that had caused me to gain weight. So, you know, I even went to Italy early on in the program. I think I was like a month into the program. And I went to Italy for a week. I never had any pasta. I think I had one glass of wine. I never had a dessert. And it wasn't hard at all. because I had made this commitment.

And, you know, I just wanted to keep moving forward and didn't want to go backwards. I'm impressed. I'm impressed. Well, conscientiousness helps there, I think. I talked in one of my recent podcasts about how people with high BMIs have increased risk of, you know, bad side effects of COVID. And someone pointed out that there's some question around this. I looked at it, it is true. The risk goes up for men, higher BMI than 40 women, 45.

So once they get to the kind of those levels, there is increased risks of issues. But I think people are really sensitive nowadays to kind of like how we talk about obesity or talk about, you know, like there's people have experienced so much shame around this. And so I just want to say, and this is what I wrote in this email to this person who was concerned, I said, you know, this is not something that. I'm like preaching from the choir. It's like, it's a struggle. You know, I'm like, I'm like, still struggling with it. And I think in the middle of COVID, it was like not helpful. You know, people talk about like the COVID 20 or the COVID 30.

Right. No, it's a big struggle. Lots of people in my family have, you know, struggled with it. But I, you know, I was very motivated to try to avoid the health problems associated with extra weight and you know it took a lot of support it really did i there's no way i could have done that without professional help yeah and i i appreciate you both talk about how in your own journey it there was initially you didn't want to seek help there was even as a psychiatrist you experienced stigma towards getting help right oh yeah which i've i myself have experienced that it's like it's kind of a um

there's a certain level of like irony you know it's like we we both are in this field and see patients all day but we don't want to be a patient right i think no one likes the idea that their mental life is somehow out of their control or their especially their mood is out of their control or their thoughts are out of their control nobody likes that um it's a hard thing to accept because our identity is so you know tied up with our our mental life. Right. Yeah. And so identity, yeah, it's kind of like the fourth perspective is life story, the meanings that we give to things. So we talked about disease, personality, behavior. So life story would be the fourth one. Tell me a little bit about what that is. You mentioned one of

my favorite authors, Victor Frankel, Man Search for Meaning in your book. So I feel like we have some some natural sort of like-mindedness there. Yeah, so, you know, the life story perspective is really about the meanings that we give events in our life, how we deal with things, and, you know, how we deal with them emotionally or cognitively, the, you know, the thoughts we have, the stories we tell ourselves. And, you know, this is, you know, the way I like to think about patients, people, in general, people are complex, and everybody has a life story, and everybody has a personality. Now, not everybody has a behavioral disorder, and not everybody has a psychiatric disease.

But, you know, when people come to us with psychiatric problems, I usually start by thinking about the life story. Then, you know, I think about personality because everybody has those two things. And then after I get through those and understanding those aspects of that person, I'll start thinking about behaviors, start thinking about diseases. But even if somebody has a disease like schizophrenia, you know, and we can explain part of their problems on the basis of the disease, other aspects of that, other perspectives are relevant to someone who's coming with a psychiatric disease because that's, that's, they've given that disease meaning.

They're telling a story to themselves about that disease. You know, why did this happen? Was it because of something that, and if they're not telling a story about it, their family maybe, you know, is this because, you know, I wasn't a good enough person or is this, you know, quote unquote karma? Or is this a random act of tragedy? I mean, people tell, you know, you, and also you get, knocked off your natural trajectory.

You know, you might be a college student, have your first episode of psychosis, and then you have to leave school. And people tell themselves a story about that, too. Does that mean I'm a failure? Does that mean I'm never going to, you know, be able to, you know, have a relationship or have children or whatever? So the life story perspective is really about the meaning you give experiences in your life. and those experiences include the experience of having a disease.

Yeah, I think that's so important. And I feel like with schizophrenia, what I've found is that it's like, once they're on the antestogotic for several months, then you start having those conversations with them. It's like as they look back, you know, and they're like, oh, but I attack this person. I have this court case. What does that mean to me now?

I'm not, there's nothing violent in me at this point, but I'm still having the manifestation of these events. you know, and the meanings that come with that. And what does it mean to have schizophrenia? I think a lot of patients really grapple with that and struggle with that and not wanting to have a chronic diagnosis. Or what is the meaning of taking these medications that I have to take and side effects? Yeah, I saw a really interesting study.

It came out a couple of years ago, I think, that looked at people with schizophrenia and it looked at their symptomatic recovery. their functional recovery and then their personal recovery in terms of their sense of meaning, purpose, self-worth. And it was really interesting to me that even with a quarter of people, 25% of people in the sample that had schizophrenia, even though they had no functional recovery and no symptomatic recovery, were able to have personal recovery. We're able to say that my life is worth something that my life has meaning.

And to me, that was really inspiring, that despite this, you know, severe psychiatric illness, despite not being able to function at the way that they had been functioning, not being able to recover from their acute symptoms, they were still able to experience a personal recovery in terms of a sense of meaning. And we don't talk much to our patients about that. We tend to focus so much on the functional recovery and the symptomatic recovery. Yeah, so important. And it's what pulls people through the hard times, the meaning that they give to things.

You talk about the importance of community work. I really liked your thoughts on work. I think that's we don't talk enough about the positive, psychological benefits of working. Can you mention that a little bit and how that might tie in with meaning and life story? Yeah. So this actually was suggested to me after the book was finished by someone. And I was like, why didn't you tell me this before the book was finished? Because it was a great way of framing the relationship between the four perspectives that I talk about in the book and the four pathways to flourishing that I talk about in the book. And this person suggested that,

the life story is really about the meaning that we give to past events and that the flourishing pathways are how we're going to be dealing with things in the future and the meaning that we're giving things for our future. And so this work comes out of Harvard, Tyler Vanderweil is this statistician, epidemiologist who's looked at these large data sets and looked at people who are flourishing in life, defined in the ways that philosophers have defined flourishing. for millennia, happiness, life satisfaction, close social relationships, meaning and purpose, character and virtue, mental and physical health. And it's looked at people who enjoy those things. And then it looked back over their life to see what these people had in common. And what they had

in common were strong connections with family, work, education, and community. And his work was focused specifically on religious community because that's the community data that's often gathered in these large epidemiologic data sets that run for 30 years or so. And so family work, education, and community are the four pathways. And so thinking about patients who come to us, you know, I'm addiction medicine certified, so I think a lot in terms of patients with addictions. And I often found that it was really, I worked for 10 years at the Center for Addiction and pregnancy, mainly pregnant women who were using heroin during their pregnancy.

It was relatively easy to help the women stop using during pregnancy. There were a lot of internal motivating factors, you know, in terms of wanting to do the right thing by their baby, but there are also external factors like wanting to retain custody of the baby when the baby was born. And so it was relatively easy for people to stop using during pregnancy. But then, you know, in the postpartum period, it's a stressful time, of course, but also it was a high time for relapse. And I see your sadness on your face as you as you talk about that. I love these women.

But, you know, it's a hard time for relapse and, you know, hard to sustain the recovery. And what we found and what you know is true with people with who we treat for addiction is that we often say, you know, you need to go to AA or NA and establish a community of people who aren't using drugs or alcohol. You need to get a job to have some A distraction from boredom, but also to have some sense of meaning and purpose and people who are depending on you. And then we also will commonly recommend that people go back to school, complete their GED if they dropped out of high school or go back to college. And again, so that they could not only learn and stimulate their mind and not be bored, but also to be able to get better jobs that are more meaningful. And then also at some point to reconnect with their family. A lot of people with addiction, as we know, burn bridges with their family through the things that they've decided to do to obtain drugs like stealing or lying and things like that.

But all those pathways, family, work, education, community are really important to sustain recovery. And I would say not just recovery from addiction, but recovery from other psychiatric problems. Even grief, which I don't think is pathological, but it can is a problem for which sometimes people come to for professional help to help them deal with a loss. even somebody who's experiencing grief might benefit from reconnecting with a community, their faith community or another community for support to get a job if they hadn't been working or a volunteer job, going back to school, other things like that. These are really important pathways to well-being. Yeah, really good, really good.

And you talk about one of your patients with schizophrenia, you go off, he got to college and he was volunteering and he met he met a girl he was volunteering at a mental health place and he met a girl because the girl was volunteering there and so she had more patience and understanding of him with his diagnosis I thought that was wonderful and and you know he's doing so much better right and at first he attributes it only to the medication I think and then you're like, well, you have a lot of these things that you're doing, right, that are good, that are life-giving and these relationships you're building, these connections with your community, so important.

Yeah, I mean, medications do help get people to a state, as you said earlier, you know, where they're cognitively available for psychotherapy as well as to work on some of these other aspects of their life. But as we've seen with that study with the people who didn't have functional recovery or symptomatic recovery, sometimes even when someone's still in the acute phases of their illness, they can talk to someone and who can help them find meaning and purpose in their life. Yeah. Very good. Okay. Do you mind talking a little bit about your brother and the situation that you share in the book about how he committed suicide and just what that journey has been like for you. Yeah, so, you know, I had no interest in psychiatry when I went

to medical school. It was really the last thing I wanted to do because I'd had such personal experience with my brother who had psychiatric problems from an early age. This was long ago, and in those days, there weren't many available treatments for ADHD. He had learning disorders. He had probably what we'd call now intermittent explosive disorder. And eventually, he developed a mood disorder for which he had a long psychiatric hospitalization and substance use disorders. He had a cocaine use disorder and an alcohol use disorder.

So, you know, it was a little too close to home. for me to want to do this professionally. And I really hadn't been impressed with the psychiatrist that I'd come in contact with through that were involved in his care. It's painful sometimes to just like walk and see subpar care. And you're not like ecstatic about these people who are trying to help him. Yeah. I mean, I have vivid memories of, you know, the ambulance coming.

to involuntarily take him, you know, to a treatment facility when he was a teenager. And these are, these are, you know, talk about traumatic events. Yeah, yeah, the images stick with you. Yeah, these are awful, awful times. But, you know, he had, because of his drug use had been involved in the criminal justice system. He'd been incarcerated several times. And of course, that's where a lot of people with mental health problems are. You know, they're in jails or prisons.

And he got treatment there, but he didn't get treatment when on his last, when he was released the last time. And within months, he relapsed on alcohol using alcohol. Of course, he knew then it was going to mean that he was going to lose the job that he had, which meant that he wouldn't be able to pay for his health. house. It estranged him from the mother of his child so that he wasn't going to be able to have contact like he had with his child. And he ended up taking his life right after a Memorial Day holiday. So it was very tragic. Everybody around him was shocked because they had no idea what was going on within him. Oh, yeah. I mean, it's just really frustrating. And there's no

like solution right to this, unfortunately, because it's like it's permanent and it must have been really frustrating that he didn't connect with help when he got out and the situation with the job. It's like painful. Yeah, there's a lot. I mean, there's a lot of, you know, lapses in the system, a lot of inadequacies in the system. You know, people do have problems accessing care. And then stigma is such as still, you know, a big, a big barrier for people seeking help, even those who have access to care, don't seek it because of concerns about stigma. And also the discrimination in terms of the way the, you know, insurers view these problems differently from non-psychiatric medical problems. Yeah. Yeah. So, so you have built a life to help.

people, you know, in addiction with forensic issues going on. You've built kind of a life to to help people who couldn't have, who, like, unfortunately, like your brother wasn't helped. I don't know if you see the link between those things. Well, you know, I don't know how causally linked they are, but I certainly feel great in some ways for the empathy that those experiences have brought me so that they do, I think, connect with patients, including patients with addiction and can empathize with their experience and certainly view them as no less than I am in this world. I mean, these things can happen to any of us.

And, you know, it's a very unfortunate situation when it happens. Yeah. Yeah. Well, I think you're entitled to, like you said, grief is a normal human process. It's normal. I have grief. And I tell patients who have had such situations, it's like normal to have grief the rest of your life. You can have that loss and you can feel that loss. And I think it's very, like, as I'm reading the book, it's like, I think I was surprised. at how vulnerable you were, just telling your history, like, this is my, the perspectives approach to my history, my disease, personality, doing life story. And I don't think that there's a lot of people who are doing that. I think there's more people now,

and I think it takes away stigma, but it definitely takes a lot of courage, right? Because I think you also had, you were in that place at one point, where you're like, I don't even want to seek treatment. And now you're at this whole other place now where you're like a professor, you know, at this great institution,

writing books and sharing your story in a vulnerable way, hopefully to help people reduce their own stigma as well. You know, so if you're a provider and you're listening to this and you're like, you know, I'm kind of on the fence, should I get help, should I not get help? What would you say to that person that might kind of help them feel like they could actually reach out? Well, I mean, these are very treatable illnesses. I think that's the number one thing to know. And it pains me when I have professionals who are, you know, consulting me, but reluctant to get help or to stay in treatment and are concerned about stigma and things like that because they're just suffering needlessly. Because as I said, these are treatable illnesses. I think, you know, there are protections in place.

that will prevent discrimination from your employer. I've seen people who have had terrible, terrible psychiatric problems who have been professionals who've gone on after treatment to resume their professional careers and make successful lives for themselves. And I'm talking about some really, really severe illnesses, psychotic illnesses, heroin addiction, you name it. You know, even what you think is the most untreatable situation, there's always hope. And that's what I would say. And I, you know, I really, obviously, there is discrimination still against people with psychiatric

illness, but that is becoming less and less. and there are legal protections in place to minimize that. Yeah, yeah. Well, I applaud you for your courage. I'm wondering, you know, you've written about Twitter, social media. What do you think about psychiatrists putting themselves out there telling their story? Any advice for them? Well, you know, it's an interesting thing.

So I train a lot of psychiatry residents. work with medical students at Hopkins. And, you know, some of them will ask me, you know, they'll say, they'll confide in me and they'll say, oh, I've had electroconvulsive therapy or, you know, I had a suicide attempt or I had a family member with a suicide attempt or suicide. Should I say that to the patient? And I typically recommend against it. I mean, I'm disclosing this.

I'm not taking new patients on. I've had patients that I've been seeing for 30 years. They know me. They're comfortable with me. I'm comfortable with them. But I think when you disclose too much, it really puts you into, it can jeopardize a relationship and it can make it more about you than the patient. What I advise people to do is to use those experiences of their own ECT or their

own suicide attempts or family members suicides to use that to develop their own rapport with the patient. So I might say to a patient who's having suicidal thoughts, your family would be devastated. They would never get over this. And that's using my own experience, not only personal experience with myself, but knowing of other people who've had these experiences professionally, to empathize with the patient and to discuss these matters. Or, you know, I've treated a lot of people with electroconvulsive therapy, and, you know, most people don't regret having had that and feel like it saved their life and are really grateful.

So there are ways to use your own experiences without disclosing them as your own experiences to build rapport and to help support empathic relationship. Yeah. I think I want to just reiterate and agree with that and that, you know, there are some people, you know, three, four years down the line when they're your patient, it's like you can share stuff. But I think when someone share something initially, there are. experience may be very different than our own. So it may, and also people are looking for empathy and comfort, and it can take away from their experience to then jump into your own experience and be like, well, I've done this or I've been through this. Oh, exactly. And people then can set up, it can set up some expectations. Well, you know, you're different from me. So, you know, that might not

work for me. I don't think it's very helpful because it sets up that or people might be disappointed if they don't get better with the first medication they're tried on. Well, you know, why did that work for you? And I just think it sets up a problematic dynamic. Yep. This is the same reason like in my office I'm not going to have pictures of my kids. I'm not going to have pictures of my family. You know, in the podcast, I may leak out information about myself over time, but I actually feel like, you know, I learned a whole lot more about you than I've probably leaked out in this whole time of doing, you know, 130 plus episodes. I'm older. I'm phasing down my career. But I will say that on social media, my rule of thumb is to never say anything that I wouldn't want a patient to know. Okay. Yeah. That's good. That's good. Yeah. I think it's hard because on one hand, we want to be authentic on social media or like, you know, we want to, like, there's some.

there's a certain degree of like, you know, just being real about things. But on the other hand, it's like, you know, yeah, I agree with that. It's, you know, what would you want your patients to know? And then also, like, patients will see what you're posting and they'll think that you're posting about them. So you have to be careful about that. Um, so yeah, it's tricky. Yeah, stick to sports. That's my rule of thumb. Oh, okay. So you're a Steelers fan and I'm a Ravens fan. We can still, we can still be a have a doctor-patient relationship i think yeah yeah there's an art in sort of being able to talk about things in a way where it's like you know it's not like there's also the false vulnerability that's sort of popular about like you know putting on this like vulnerability thing

where it's like you're not really vulnerable but you're putting out that you're feeling vulnerable just to gain connection so there's like this kind of like place where i've got into with my social media where it's like, I don't know, I'm just kind of burned out on posting. I agree. I agree. I look forward to the day that I am able to cut the cord there. I don't want to go into the metaverse. No. You're not going to be in the metaverse. I've had a glimpse of the metaverse and decided I don't want to go there. It's not for you. Rather be in nature. Very good. Yeah. And you talk about exercise as well, and the value of kind of moving, anything you want to mention on that or how it's helped you?

Yeah, I mean, I like hiking. I like walking. I won't glorify it to hiking. It's not like I'm going up Mount Kilimanjaro or something. We can picture that. I do think getting out, I think daily morning exercise, well, we know that daily morning exercise is one of the few things we can do to help our sense of well-being. And so that's what I do. And I enjoy it.

And, you know, I think I've been now so conditioned in this behavior of walking that if I don't go out, I really miss it and crave it. So that's a great point to get to an exercise. Yeah. Yeah. I think there's, I think more about, so I go rowing every morning. I live near some lakes now. And so I go, I go out in a one-person, nice German boat that took a year to get here. but it was worth it.

You digress. And so I get out there in nature and it's just absolutely exquisite. So it's like pleasure and it's like exercise at the same time. So I'm thinking more about kind of finding that place of like sometimes it's good to do something which is not necessarily just pure pleasure with working out right. But then I think the majority of our workout should be something that's like in nature that we enjoy. That gives us a sense of pleasure. Yeah, I love.

actually love being out in nature. It's really a balm, I think, for my soul to be in a around non-man-made or human-made structures. So yeah, I just think it's, to me, it's really refreshing and can be transcendent. It can be so beautiful. Well, for my audience, check out this book. The audio, I know a lot of my listeners are like big into audio. The audible version is something you can listen to it on double speed, one and a half speed. It's probably perfect for this book in particular, but it's really, really well done. It's something you can give to patience. So if you take a listen to it, do me a favor and put in a review for her on Amazon and mention that you heard her on this podcast. And that way,

That way I can brag to future authors that I have on here that, look, so many people will write you reviews if you come on my podcast. So, yeah, it was really good. Any final thoughts you want to put out there to my audience of psychiatrists, psychotherapists, nurse practitioners, PAs? Yeah, I mean, just to build on what you were suggesting. So I do think that, you know, the foundation of this approach is taking a really thorough history. and getting to know your patients, your clients as people and understanding, you know, what they've been through in their life before they've come to your office, understanding who they are as a person in terms of their personality. That's really essential to developing a psychiatric formulation and a treatment plan.

And even though it is a little more time consuming up front, getting the diagnosis, right, getting the treatment plan right the first time. We'll just save months, if not years, of suffering for the patient. Great. Well, we will plan on some sort of episode two where we go through the history taking in particular, all the nuance there, go through that first book of yours. And yeah, any other thoughts you have? Just shoot me an email. And we'll go from there. Well, thank you, David. It's been really fun. Great, great conversation. Thank you. Very nice to meet you. Okay, take care. Hi, this is Trent. I'm the producer of this podcast, and I wanted to make a quick announcement.

Dr. Puter will be holding a Big Five personality webinar on February 1st, 2022. Admission is $95, and this includes the Big Five personality test, which you will take prior to the webinar, so you can then receive and understand your results at the webinar. All proceeds from your admission will be donated to a nonprofit 501c3 called Mental Health Education and Research and a specific project to help other medical education projects. So if you are interested, go to Psychiatrypodcast.com slash webinar. That's psychiatrypodcast.com slash webinar. And if you are listening to this after the date, then you can check to see if any future webinars are

planned using the same link. We hope to see you there.