Episode 135: From Survive to Thrive with Margaret Chisolm, MD
Kenza El Machkour, Hanan Alaali, David Puder, MD
In this article 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.
Dr. David Puder, Kenza El Machkour, Hanan Alaai have no conflicts of interest
Dr. Margaret Chisolm only conflict of interest is her book From Survive to Thrive
The Four Perspectives Are:
Disease- Something the patient has
Personality- Dimensional/who the patient is
Behavioral- Something the patient is doing (ex: substances, eating and/or behavioral disorders)
Life story- The meaning the patient gives to their life events; something they have encountered
A Well-Rounded Approach
Using these four perspectives allows for a well-rounded observation, whereas singular perspectives like “trauma vs. not trauma” could overlook how a person is wired and may prevent a complete resolution. Dr. Chisolmactually avoids the labeling “traumatic event” because it's very dependent on how a person processes the event. Two people can experience the same event and one may process it as a trauma while the other may not. Trauma is not the event, trauma is the interpretation of the event, which will be dependent on temperament.
For example, after 9/11 there was a patient who directly experienced the event but didn’t even lose a night of sleep and who wouldn’t define it as traumatic because he had a non emotionally reactive temperament. Whereas, a person with high neuroticism halfway across the world did process 9/11 as a traumatic event. The difference wasn’t proximity to the event, but their temperaments.
Observation vs. Interpretation
As clinicians, we also have to be careful to distinguish observation vs. interpretation. We all have biases and have to determine where to put the lens of empathy and how to diminish our biases. Clinicians can assume that because they would process something a certain way and feel a certain way that the patient would also respond the same way (such as being upset), and this is where observation vs. interpretation comes in as a tool. As we are trying to understand the mental life of someone else when we don’t have objective measures for collecting that information, it can make us prone to even more biases. Instead, we need to meet the patients where they’re actually at, not where we suspect they will be at. We can all have blind spots if we only see patients with our own lens.
The Four Perspectives
Disease
An example of disease is schizophrenia. It has stereotypical symptoms, regardless of where you are in the world. Nothing a person has done has brought it on; it has more to do with brain structure than events that have happened to a person. Other examples are dementia, acquired brain injuries, and bipolar mood disorder.
Personality:
Personality is both cognitive ability (IQ) and personality (Big 5)
The Big 5
When it comes to personality, Dr. Chisolm notes that the Big 5 personality traits are not good or bad; context is needed and how these traits affect us in different situations must be taken into consideration.
Dr. Chisolmshares her Big 5 personality profile with us in her book:
Agreeableness: A little disagreeable due to inflexibility (i.e., changing plans)
Neuroticism: High (shouldn’t be based on appearance, Dr. Meg is calm, but still high in neuroticism)
It is interesting to note that psychologically-minded people are often high in openness because psychology is based on abstract thinking and the understanding there is no right or wrong. It is a profession that also embraces ambiguity.
Openness tends to be a temperament that can indicate if a person will fare better in therapy; people with low openness can be more black and white—there is a broken bone and now it is fixed—instead of working through the process of self-awareness and change/growth over time.
Neuroticism is more an internal experience rather than an obvious, outward behavior. A person can appear calm, but be internally worried about a lot of things.
Behavioral (Doings):
Behaviors are the acts of filling needs as related to the brain circuitry or exposure. As a species, we have needs we are hard-wired to crave in order to survive. Our bodies and brains are hard-wired to go through puberty, to have a sexual appetite, as well as an appetite for eating/feeding ourselves. We become satiated, and then develop an appetite again. We develop foods we like and foods we dislike. We are wired to need sleep. These are all behaviors that revolve around brain circuitry.
Then there is exposure, which is cravings and conditionings to things not needed for survival, such as developing a taste for alcohol or developing a taste for a food—we get conditioned to enjoy it and begin to feel bad when we don't get it. We develop more drive for these things and our free will to choose them narrows (which is different from a disease such as schizophrenia). In this way, substance disorders and eating disorders are similar because they deal with the drive cycle.
There are people who do not believe in free will and rather in pre-conditioning or destiny. Studies have suggested positive things consistently came from believing in free will/choice, possessing a sense of agency in one’s own life.
Once a patient was speaking about food and weight loss. He spoke about it as though he didn’t have control over food, like he had no choice. Finding agency, as in weight loss, is imperative because it requires a conscious decision and a readiness to make a change.
Dr. Chisolm shares her story of partnering with professional support in order to lose a significant amount of weight. She experienced agency in these choices, and as she remained accountable, her drive to eat decreased and she became conditioned to choose the prescribed foods with ease. The difference between diseases and behaviors is in the ability to choose. Behavior is self-driven, while disease often does not involve choice. Developing a sense of agency helps tremendously when it comes to behavior.
Life Story
Life story is the meaning that we put behind our experiences and the meanings we give events, emotionally and cognitively. Dr. Chisolm references Victor Frankl’s book, Man’s Search for Meaning, where Frankl documents his experiences in finding hope and purpose while in a concentration camp during World War II. He was able to assign positive meanings and hope to even his most tragic life events and, as a psychiatrist himself, was able to use these experiences in his practice after the war to help people recover from a variety of mental challenges and disorders.
Everyone has a life story and personality, although not everyone has a behavioral disorder or psychiatric disease. Because of this, thinking about the personality perspective first is helpful. It is important to remember that people have both personality and life stories before having a disease or a behavioral problem. For example, part of schizophrenia may be explainable by certain congruences with the disease perspective, but other perspectives are meaningful, as well. These patients are telling themselves a story about the disease (or their family may be). They may wonder if they were not a good enough person or if it is karma, thinking through why this is happening to them.
Examples of Life Stories
What kinds of stories do these patients develop around the experience of having a disease or developing a mental illness? The onset of these illnesses can really knock them off their trajectory, such as having a first episode of psychosis and having to drop out of college. They may begin to question if they will be able to have a relationship or a future, and potentially feel like a failure.
To further use schizophrenia as an example, the self-narrative around their life story really begins to come out after they have been taking antipsychotics for a couple of months. The meds begin to give them the ability to self-reflect and they begin to ask questions about what it means to have schizophrenia and what the side effects are of the medicines they are taking.
Interestingly, Dr. Chisolm cites a study where 25% of patients in a sample study that didn’t have functional or symptomatic recovery in their schizophrenia were still able to have personal recovery, meaning they were able to say that their life was worth something and had meaning. Even though they couldn’t recover from their symptoms, they were able to find meaning, despite the fact that they could not function as before or experience recovery.
Meaning is really what pulls people through the hard times (another running theme in Frankl’s book). Integrating this language into patient care is impactful.
The Four Flourishing Pathways
Life story is about the meaning we give to past events. How we will deal with things in the future has been termed “flourishing pathways”. Epidemiological data sets of people who were considered to be flourishing (as defined by ancient philosophers) were evaluated by a statistician out of Harvard with the goal of discovering their commonalities. Four pathways to living a more flourishing life emerged: family, work, education, and community.
Family: Addiction burns many bridges within families and mental illnesses can create difficult relational situations or dynamics. Reconnecting with family is a powerful tool to foster a flourishing life.
Work: Provides a sense of meaning and purpose and is also a helpful distraction from boredom.
Education: Pursuing further education, such as getting their GED or enrolling in college, stimulates the mind and paves the way to better jobs that are more meaningful.
Community: This can look like encouraging addicts to go to AA/NA meetings and establishing a community of people who aren’t using, forming healthy relationships.
Each of these is highly important to help sustain recovery from not only addiction, but other psychiatric problems. They are also relevant to grief, and although it is not pathological, would benefit from focusing on these four areas.
Dr. Chisolm’s Journey into Psychiatry
Dr. Chisolm actually did not have interest in pursuing psychiatry when she entered med school. Growing up, she watched her brother struggle with mental health disorders that unfortunately ended with his suicide, and observing her brother’s care was discouraging and led her away from the field. Her brother struggled with ADHD, learning disorders, intermittent explosive disorder (in today’s terms), and eventually a mood disorder (for which he was hospitalized at times) and substance abuse disorder (alcohol and cocaine). He was incarcerated (like so many with mental illness) and he actually received treatments while in prison, but this treatment did not continue once he was released and within months he relapsed on alcohol. This led to a series of events that culminated in suicide. There were not many available treatments at the time, and she had been disappointed in the subpar professional help, such as psychiatrists, involved in his care.
Eventually, her stance changed and she became interested in helping this community and being a part of the solution to the faulty system. In the end, this experience pushed the professor to highlight this part of her life in the book, and today she works with people who struggle to find help and are caught up in the loop of addiction (heroin addiction mainly). Her experiences have helped her develop a deep empathy for these patients and the ability to see them as equals in the world.
Seeking Treatment for Mental Illness
When it comes to seeking treatments, unfortunately certain barriers exist that can prevent people from accessing care or seeking it at all. Stigma is a major barrier that keeps professionals and the general population from seeking care. They have fears of being discriminated against at work or by their insurance company. Additionally, the system is very broken when it comes to helping people who are incarcerated. It can be hard to simply access care.
It is hard to seek help from an emotional standpoint, as well. We don’t want to admit that our mental life or mood is out of our control because our identity is tied up with our mental life. Therefore, the need for help becomes difficult to accept because it shatters our identity.
To people who are on the fence in seeking care, Dr. Chisolm offers her encouragement that these are very treatable illnesses and to not suffer needlessly. There are protections against discrimation from employers (the stigma still exists but it is becoming less and less). She has personally seen and treated a large number of professionals who have recovered from severe mental illnesses and successfully resumed their high-capacity careers after treatment (even from very severe mental illnesses). There is always hope!
Relating to Patients
Integrating the four elements (family, work, education, and community) is a good thing when it comes to talking about suicide with a patient who has suicide ideation: For example: “Your family would be devastated by this”.
However, Dr. Chisolm advises against relating to a patient who has experienced suicide attempts first or secondhand because it can jeopardize the patient/therapist relationship. Instead, we should use our experiences to develop rapport with the patient and support an empathic relationship; we can use our own experiences without actually disclosing them. There are times that it is possible to disclose certain things to patients, maybe 3-4 years down the road, but initially when they disclose, patients are looking for empathy and comfort. Using our own experiences to relate to them does not prove to be helpful and can actually lead to problematic dynamics (They may think, “Why didn’t I respond the way you did? Why did the meds work for you and not me?”, etc.). Additionally, too much disclosure can make it more about the clinician instead of the patient.
The Therapeutic Effect of Exercise
Daily morning exercise, such as walking, is shown to help with an overall sense of well-being. With consistency, we can become conditioned to miss it and crave it when we don’t get it, much like substances and food. Contact with nature can bring a transcendent, out-of-the-ordinary experience. Dr. Chisolm enjoys daily walking and refers to it as a “balm” to her soul, finding it refreshing to have some time away from man-made/human structures.
Final Advice
Take a thorough patient history. Get to know the patients as people. Understand what they’ve been through in their lives before they came to your office. Understand who they are as a person in terms of personality. This is more time consuming up front, but it will save months or years of suffering when it comes to getting the treatment plan right the first time. It also greatly diminishes the risk of multiple diagnosing or rediagnosing.