Sharon Packer, MD

When English journalist and blogger Katie Mills asked me about gardening and its benefits for mental health, she reignited my interest in William Wordsworth. How fitting is that?

Wordsworth was an English-born poet, born in the countryside of Cockermouth. His mother died when he was almost 8 years old, and his father passed away 5 years later. After which, young William was sent to live with relatives.

 The year 2020 marked the 250th anniversary of Wordsworth’s birth. But as we reread his poems and rejoice in his ideas today, he is metaphorically reborn again and again. Some of those ideas are related to his recovery from depression, and other ideas can be considered deterrents of future depression.

Wordsworth’s impact extended far beyond the British Isles and well past the 19th century, for he birthed the romantic movement that spread across continents. He remains one of our most revered poets, with his 24-line “Daffodils” being the most-read poem in the English language.

 between Wordsworth’s poems, depression, and seasonal affective disorder and specifically about the beloved “

,” which opens with the words, “I wandered lonely as a cloud.”

 This implies that his seasonal affective disorder was dissipating—or possibly that a hypomanic state was developing—or that he simply exhibited spontaneous poetic impulses, which are sometimes called the “madness of the muses.”

Although seasonal affective disorder is not at the forefront of our thoughts, given that the darkest days of autumn are behind us, it is worth revisiting other ways that Wordsworth offset unwanted negative thoughts that pop up in almost all of us from time to time, and not only in autumn. Repeating Wordsworth’s words, which are excerpted from Mills’ blog

 and appear below (and on countless placards in Pinterest posts), may offer some solutions.

On the surface, these phrases sound similar enough to other examples of Wordsworth’s romanticism, where he extols the spiritual forces of nature and invokes its “natural supernaturalism,” to use literary critic M.H. Abrams’ terminology.

 It is easy to be smitten by these sentences for their poetic value alone. However, if we take a less ethereal approach to these lines and treat these passages as metaphors for psychiatric lingo, we can view this stanza as a prelude to cognitive behavioral therapy (CBT), which teaches us ways to change our thoughts and challenge spontaneous “cognitive distortions” that cause distress.

Per Wordsworth, and per CBT theories, we can indeed choose the way we think and thereby change our moods. In contrast to the determinist psychoanalytic stances that preceded redaction of reigning theories and invention of CBT by Aaron Beck, MD, we can rephrase reflexive reactions and replace maladaptive ideas—and thereby alter our attitudes and the emotions that follow. Per Beck, it is within our power to reverse the ways that we react to the world, to ourselves, and to others. In turn, that attitudinal about-face influences the way others react to us, and a positive chain reaction ensues.

Through our own volition, we can prune and pluck bad thoughts—those cognitive distortions that are akin to unwelcome weeds—while watering and nourishing better thoughts so that alternative thoughts blossom into fragrant flowers. Those flowers, in time, will drop their own seeds, setting off incessant cycles of flowers, flowers, and more flowers. We need not wait to “nip it in the bud,” as the expression goes, for flowers that we plant from seed can thrive and survive, with a little effort on our parts, rather than being overtaken by pernicious weeds.

By substituting clinical terms, such as cognitive distortions, for Wordsworth’s more literary rendition, we can retain the essence of both CBT theory and Wordsworth’s insights. Like growing flower gardens from seed, learning CBT skills takes time and effort—but not too much time and not too much effort. Although the end effects of sowing seeds or learning CBT are admittedly not instantaneous, the results that arrive the next season promise to repay our diligence many times over. We ourselves can plant seeds of happier and healthier thoughts that are akin to Wordsworth’s flowers, which appear after sowing seeds in early spring, watering the soil when needed, and following a few more simple steps.

It is worth remembering that wildflowers also spring from the soil spontaneously, without any human effort at all. The beauty of those wildflowers can overshadow unwanted and unplanted weeds—as long as we uproot those pesky, persistent weeds before they spread and strip the soil of nutrients needed for flowers to survive. Weeds can grow tall, block the sun, and absorb the rains to overpower our precious and more precarious flowers. Similarly, bad thoughts can eclipse good thoughts if we do not intervene. In other words, if we “weed” those bad thoughts from our brains by using CBT and other techniques, we can enjoy the equivalent of fragrant flowers in our minds.

To simplify matters, and to incorporate Wordsworth’s metaphors, we can sort our spontaneous thoughts into “weeds” and “wildflowers.” Whenever a bad automatic thought—also known as a “cognitive distortion”—pops into consciousness, we can remind ourselves that it is a “weed” and dismiss the idea immediately by categorizing it as such and arguing against it. “Jumping to conclusions,” “all-or-nothing thinking,” “expecting the worst,” “ignoring the evidence,” “catastrophizing,” “magnifying,” and “minimizing” are all weeds that we can uproot to make way for our favorite “wildflowers.” This is a far less unpleasant approach than the “aversive conditioning” advocated by certain behaviorists, who recommend wearing a tight rubber band around one’s wrist and snapping it against the skin when unwanted impulses or ideas occur.

My simple approach might not appear in Beck’s standardized CBT training manuals, and it is probably too simple to merit a grant that lets us test it experimentally to confirm its validity via “evidence-based medicine.” But it is easy enough to use on ourselves and test informally. My anecdotal data to date confirm that this technique is a useful warm-up for more time-consuming and standardized CBT techniques—and sometimes it is sufficient in itself.

We can just as easily compare this approach to time-tested “creative visualization” strategies used to treat people with posttraumatic stress disorder who suffer from spontaneous flashbacks of adverse experiences. Some sports coaches also use variants of creative visualization to encourage their charges to achieve more. In creative visualization, we substitute pretty and pleasant mental images for their annoying and anxiety-inducing antecedents. What can better offset automatic images of strangulating weeds than invoked visions of fragrant flowers, as seen in the mind’s eye?

Wordsworth had the right idea, even if current clinical terms were not part of everyday parlance when he wrote. And that is probably for the best because we might not have been graced with Wordsworth’s verses had effective clinical care been available in the early 19th century. Please forgive me that I feel compelled to end this article with a nod to Freud, who admitted that “Everywhere I go, I find a poet has been there before me.”

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

1. Wordsworth’s years of happiness and heartache. National Trust. Accessed January 10, 2022. 

https://www.nationaltrust.org.uk/wordsworth-house-and-garden/features/wordsworths-years-of-happiness-and-heartache

2. Packer S. Wordsworth’s wisdom during troubled times. 

. March 27, 2020. Accessed March 7, 2022. 

https://www.psychiatrictimes.com/view/wordsworths-wisdom-during-troubled-times-0

3. Packer S. Daffodils as antidepressants (what Wordsworth knew). 

. April 16, 2014. Accessed March 7, 2022. 

https://www.psychiatrictimes.com/view/daffodils-antidepressants-what-wordsworth-knew

4. Mills K. Gardening for physical and mental health. Poshh blog. September 24, 2021. Accessed March 7, 2022. 

https://poshh.co.uk/living/gardening-for-physical-and-mental-health/

Natural Supernaturalism: Tradition and Revolution in Romantic Literature

Articles

How have William Wordsworth's ideas about creative visualization influenced cognitive behavioral therapy in contemporary psychiatry?

Wordsworth, Wildflowers, and a Simple Prelude to Cognitive Behavioral Therapy

What gives people the courage to push on, even in the most untoward circumstances? Psychiatrist and psychoanalyst Victor Frankl, MD, PhD, broached this question in his best-selling book, 

 A survivor of Auschwitz himself and the founder of “logotherapy,” Frankl suggested that some individuals survived the devastating conditions of concentration camps because they found meaning in their work or in their relationships. According to Frankl, those who lost that sense of meaning simply shriveled up and died, even before the Nazis sent them to preordained deaths.

However, a comedian-turned-politician expressed his sentiments on the subject more cogently. The current Ukrainian president summed up his philosophy in a single yet striking paragraph. During a press conference on March 3, 2022, President Volodymyr Zelensky pronounced that “My life today is wonderful. I believe that I am needed. That’s the most important sense of life: that you are needed—that you are not just an emptiness that breathes and walks and eats something.”

Who among us would have guessed that Zelensky would be so optimistic, so appreciative, even so reflective at a time when he himself faces assassination threats, and when he literally watches his country go up in smoke—and when we, as bystanders, are inundated with footage of bombed-out buildings and images of mothers and children being murdered as they attempt to escape their war-torn homeland? Surely not me—yet his attitude started to make sense once I compared Zelensky’s reactions to Frankl’s observations, and when I reflected on the sense of mission that propelled so many medical students at a time when medicine was a “calling” rather than a “job.”

Zelensky did not aspire to find meaning in his own life, like Frankl and his entourage did. Rather, it appears that Zelensky has already identified what gives his life meaning, and it is the need to be needed and the opportunity to meet the needs of his people in any way available.

If we dig deep, we might find that many—if not most—physicians were also motivated by the need to be needed, so they acquired the ability to save lives, assuage pain, increase mobility, improve breathing, or whatever their specialty offers. Parents, in particular, are propelled by the need to be needed, and some fall into despair when their progeny no longer need them or reject the help they offer. Ex-military personnel also need to feel needed, which is why so many Americans jumped at the chance to join forces in Ukraine and to fight a just war that 

As psychiatrists, we routinely ask our depressed and demoralized patients why they will 

act on impulses to hurt themselves or take their lives, even when their desire to remain alive has waned. We rightfully feel reassured when individuals say that they will 

 commit suicide because someone “needs” them, be it family, friends, or even a pet hamster (as one patient recently informed me during her appointment).

At this point in time, so many of our colleagues are at the verge of burnout. Highly trained health care professionals have been leaving their posts in greater numbers than ever before. Is it because of the pressures of COVID-19, or is it simply a parallel to the “Great Resignation” that impacts the workforce overall? Or is it because entering data in an electronic health record; “treating the data, not the patient”; prioritizing administrative rules and regulations; and circumventing managed care restrictions—and tiptoeing around prior authorizations—preempts patient care, and so does not make doctors feel needed by the very patients they purport to help?

Let me answer my own rhetorical question: We know for a fact that the burnout epidemic began well before the COVID-19 pandemic emerged. So much has been written about burnout that I will not belabor the point. On its website, the American Medical Association (AMA) identifies many contributors to doctors’ demoralization.

 Some sources recommend “better work-life balance” to beat burnout—but is that the answer? It is fairly clear that most of the soul-sapping factors listed on AMA’s website share one trait in common: They make medical practitioners feel unneeded. It is better to identify creative ways to feel needed again and to help our colleagues stay in the fold—and that aspiration in itself is a good way to feel needed.

is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

Behind sandbags, Ukraine’s leader meets the media

. March 3, 2022. Accessed March 11, 2022.

. American Medical Association. Accessed March 11, 2022.

Reflections from the Russo-Ukrainian war and the importance of being needed.

“My Life Today is Wonderful. I Believe that I Am Needed.”

How fitting it is that an Englishwoman—journalist and blogger Katie Mills—reignited my interest in William Wordsworth when she queried me about gardening and how it helps mental health.

Wordsworth was an English-born poet, born in the countryside of Cockermouth. After his mother died when he was almost 8, and his father succumbed 5 years later, young William was sent to live with relatives.

 The year 2020 marked the 250th anniversary of Wordsworth’s birth—but he is metaphorically reborn again and again as we reread his poems and rejoice in his ideas. Some of those ideas revolve around his recovery from own depression, and other ideas can be seen as deterrents of future depression.

In years past, I wrote about parallels between Wordsworth’s poems, depression, and seasonal affective disorder, and specifically about the beloved “

Although seasonal affective disorder is not at the forefront of our thoughts, given that the darkest days of autumn are behind us, it is worth revisiting other ways that Wordsworth offset unwanted negative thoughts that pop up in almost all of us from time to time, and not only in autumn. Repeating Wordsworth’s words, which are excerpted from Mills’ blog,

 and which appear below (and on countless placards in Pinterest posts), may offer some solutions.

Per Wordsworth, and per CBT theories, we can indeed choose the way we think and thereby change our moods. In contrast to the determinist psychoanalytic stances that preceded Aaron Beck, MD’s redaction of reigning theories and his invention of CBT, we can rephrase reflexive reactions and replace maladaptive ideas—and thereby alter our attitudes and the emotions that follow. Per Beck, it is within our power to reverse the ways that we react to the world, to ourselves, and to others. In turn, that attitudinal about-face influences the way others react to us and a positive chain reaction ensues.

Through our own volition, we can prune and pluck bad thoughts—those “cognitive distortions” that are akin to unwelcome weeds—while watering and nourishing better thoughts, so that alternative thoughts blossom into fragrant flowers. Those flowers, in time, will drop their own seeds, setting off incessant cycles of flowers, flowers, and more flowers. We need not wait to “nip it in the bud,” as the expression goes, for flowers that we plant from seed can thrive and survive, with a little effort on our parts, rather than being overtaken by pernicious weeds.

By substituting clinical terms, such as “cognitive distortions,” for Wordsworth’s more literary rendition, we can retain the essence of both CBT theory and Wordsworth’s insights. Like growing flower gardens from seed, learning CBT skills takes time and effort—but not too much time and not too much effort. Although the end effects of sowing seeds or learning CBT are admittedly not instantaneous, the results that arrive the next season promise to repay our diligence many times over. We ourselves can plant seeds of happier and healthier thoughts that are akin to Wordsworth’s flowers, which appear after sowing seeds in early spring and watering the soil when needed and following a few more simple steps.

It is worth remembering that wildflowers also spring from the soil spontaneously, without any human effort at all. The beauty of those wildflowers can overshadow unwanted and unplanted weeds—as long as we uproot those pesky, persistent weeds before they spread and strip the soil of nutrients needed for flowers to survive. Weeds can grow tall, block the sun, and absorb the rains, to overpower our precious and more precarious flowers. Similarly, bad thoughts can eclipse good thoughts if we do not intervene. In other words, if we “weed” those bad thoughts from our brains by using CBT and other techniques, we can enjoy the equivalent of fragrant flowers in our minds.

My simple approach above might not appear in Beck’s standardized CBT training manuals, and it is probably too simple to merit a grant that lets us test it experimentally, to confirm its validity via “evidence-based medicine,” but it is easy enough to use on ourselves and test informally. My anecdotal data to date confirm that this technique is a useful warmup for more time-consuming and standardized CBT techniques—and sometimes it is sufficient in itself.

We can just as easily compare this approach to time-tested “creative visualization” strategies used to treat people with posttraumatic stress disorder (PTSD), who suffer from spontaneous flashbacks of adverse experiences. Some sports coaches also use variants of “creative visualization” to encourage their charges to achieve more. In creative visualization, we substitute pretty and pleasant mental images for their annoying and anxiety-inducing antecedents. What can better offset automatic images of strangulating weeds than invoked visions of fragrant flowers, as seen in the mind’s eye?

Wordsworth had the right idea, even if current clinical terms were not part of everyday parlance when he wrote. And that is probably for the best, because we might not have been graced with Wordsworth’s verses, had effective clinical care been available in the early 19th century. Please forgive me if I feel compelled to end this article with a nod to Freud, who admitted that “Everywhere I go, I find a poet has been there before me.”

1. Wordsworth’s years of happiness and heartache. 

Wordsworth’s wisdom during troubled times

Daffodils as antidepressants (what Wordsworth knew)

What do these have to do with CBT, creative visualization, and contemporary psychiatry?

Weeds, Wildflowers, and Wordsworth

“We usually think of what hate does for the individual hated or the individuals hated or the groups hated. But it is even more tragic; it is even more ruinous and injurious to the individual who hates.” -Martin Luther King, Jr.

On Saturday, January 15, 2022, according to the January 16th 

I am grateful to be alive,’ says Colleyville rabbi Charlie Cytron-Walker,

” and consistent with the core principle of Judaism to welcome the stranger, a man was let into Congregation Beth Israel synagogue by the Rabbi when he knocked and asked if the synagogue was a shelter.

 As Shabbat prayer continued, the man clicked a gun, and then held the Rabbi and 3 other Jewish individuals hostage, even as he praised the Rabbi on the live-streamed audio of the service, saying “I bonded with him. I really like him.” The man also said that he himself was going to die, and he did. The additional terrible irony is that Rabbi Charlie Cytron-Walker and his wife are pillars in the area for interfaith dialogue.

As the crisis continued, the suspect was identified as a Muslim. He is a British citizen who immigrated to the United States not long ago. During the hostage situation, he was described as “extremely distressed” and making “political” demands. As information emerges after the event, it seems that he might have chosen this Jewish organization because it was close to a federal prison where he wanted a prisoner freed. This prisoner was convicted of trying to kill US Army officers in 

 and conveyed anti-Semitic sentiment during the ensuing stand-off. The standoff lasted almost 12 hours, and with the active-threat training that the hostages had for such a situation, their maneuvers to flee, and the patience of law enforcement, the hostages fortunately escaped. Given our concern with 

, how the suspect got his gun needs clarification.

The Council on the American Islamic Relations (CAIR), the largest Muslim advocacy group in the United States, condemned the incident as an act of hate: “This latest Anti-Semitic attack at a house of worship is an unacceptable act of evil. We stand in solidarity with the Jewish community. No cause can justify or excuse this crime.”

Omar Suleiman, PhD, a highly respected Dallas-based Imam, also strongly condemned the attack: “…we will be there for our Jewish neighbors as they recover. The perpetrator cannot claim to have acted for any noble cause. He held a beloved faith leader to our community and his congregants hostage with no regard. And those that will use this to stoke the flames of hatred and division will fail as he did, God willing.”

Internationally, similar attacks on houses of worship targeting Muslims, like what happened at the Al Noor and Linwood mosques in Christchurch, New Zealand, on Friday, March 15, 2019; or Christians, like on the International Pentecostal Holiness Church headquarters in Zuurbekom, South Africa on Saturday, July 11, 2020; or the gurdwara Sikh Temple in Oak Creek, Wisconsin, on Sunday, August 5, 2012—all are acts whose apparent aim is to foment social and individual hate, but may also be acts committed by persons who need psychiatric care.

Connected religiously and psychologically to this event, the Jewish Tree of Life synagogue in Pittsburgh also had disastrous loss of member lives on October 27, 2018. This current incident is also liable to be a trigger for that past trauma. So said their Rabbi, Jeffrey Myers, who, in various media interviews after the hostage crisis, also maintained getting mentally stronger through vision of purpose over millennia, combined with ripples of support.

In the United States, as well as the United Kingdom, we are in a time of great conflict and divisiveness that compromises the safety of citizens. Due to projected scapegoating, those who are different usually bear the highest risk of harm.

, an international alliance of social psychiatrists and other mental health professionals of various faiths who have previously written about other conflicts in the Middle East and Afghanistan for 

. Some of the members of this alliance have also edited and written chapters for 3 books published by Springer International over the last 2 years: 

Islamophobia and Psychiatry: Recognition, Prevention, and Treatment

Anti-Semitism and Psychiatry: Recognition, Prevention, and Interventions

. SPIRIT welcomes new members interested in helping our cause.

In our mission, we have a moral, ethical, and clinical responsibility to support the survivors and tend to their visible and invisible wounds, as well as to address the ripple repercussions of the traumas as they spread out from the epicenter into society. Although there is interfaith progress, there is still entrenched cross-cultural hate. We try to research the root causes of these harmful and all too common phenomena. Though it is unlikely that psychiatry can often predict something like this by a given individual, we still might find ways to be proactive rather than reactive, try prevention rather than intervention, and instigate systemic change of the adverse social determinants of such mental problems. Psychological autopsies of perpetrators can provide valuable clues to their personal backgrounds, 

, psychological conflicts, and motives. In the case of the Congregation Beth Israel hostage situation, the perpetrator’s brother has already said he had “mental health issues.”

 and mental illness are often a volatile mix. Similarly, security reviews of what happened will hopefully provide increasingly safer guidelines for the future.

We must also reinforce the psychologically beneficial messages embedded in our current holidays. In an unusual confluence, January 17 this year includes the annual Martin Luther King Jr. Day, the Jewish Tu B’Shivat celebration of environmental sustainability, and the inaugural Muhammed Ali’s Day in Illinois celebrating peace. Together, they point the way to social and environmental justice. In the meanwhile, safety and security must be paramount at vulnerable social and political targets, including the current possibility of copy-cat attacks of faith-based communities.

But first and foremost, we must be part of the solution by refusing to be taken hostage to hate.

is a practicing psychiatrist, Providence Healthcare System, Portland,

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

serves as Kathleen & John Bricker Chair, Department of Psychiatry, LSUHSC. He also is chairman of the Board of Trustees of the Cobb Research Institute and is the 113th present of the National Medical Association. 

 is an associate professor of psychiatry at Harvard Medical School and a fellowship site director for Brigham and Women's Hospital. 

 is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the United Kingdom.

is a professor of psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on international medical graduates, culture, religion, family psychiatry, gender issues, etc. 

 is assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

 is clinical professor and chair of psychiatry and behavioral science at the University of North Dakota School of Medicine and Health Sciences.

 is professor emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada. 

 is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel. 

 is professor emeritus in psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

 is interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a fulltime research appointment as a visiting researcher at Harvard University in Cambridge, Boston.

 is medical director of the Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

1. 'I am grateful to be alive,' says Colleyville rabbi Charlie Cytron-Walker. 

. January 16, 2022. Accessed January 17, 2022. 

https://www.jpost.com/diaspora/article-692639

2. Council on the American Islamic Relations. CAIR condemns hostage-taking at Texas synagogue, working with local community leaders to learn more and provide assistance. January 15, 2022. Accessed January 17, 2022. 

https://www.cair.com/press_releases/breaking-cair-condemns-hostage-taking-at-texas-synagogue-working-with-local-community-leaders-to-learn-more-and-provide-assistance/

3. Omar Suleiman page. January 15, 2022. Accessed January 17, 2022. 

https://www.facebook.com/imamomarsuleiman

4. Gill D. Synagogue hostage-taker had ‘mental health issues,’ brother says. Daily Beast. January 16, 2022. Accessed January 17, 2022. 

https://www.thedailybeast.com/fbi-identifies-synagogue-hostage-taker-as-british-national-malik-faisal-akram

The recent hostage situation at a synagogue in Texas in indicative of a larger underlying problem. 

We Refuse to Hate

Sometimes, on a summer Sunday, I sit outside on my covered porch and contemplate my shade garden. During that time, I also think about my patients, and the lessons that my garden has taught me about them. It may sound strange to compare patients to plants—so let me explain.

Before we became physicians, and even before we started medical school, we were premeds, studying basic biology as well as botany. In Biology 101, we learned about animal habitats and which animals thrive in which habitats, and which would not survive in those same circumstances. Some settings are suitable for some creatures, whereas others are not. Polar bears, for instance, do well in the cold and the snow, whereas tropical birds and butterflies require the opposite conditions. Move those polar bears into the Amazon, and those polar bears will be no more. Many of us learned similar basic biology lessons much sooner, simply from visiting zoos.

Since most of us do not keep polar bears in our backyards, I will not belabor the point and will not pontificate about animals and ecology. Better to talk about gardens, which are more common.

In the popular imagination, gardens need sunshine, as well as good soil, and the right amount of rain, so that roses and so many other beautiful sun-loving flowers can grow. Yet I can look out on my shade garden and see many other lovely flowers which were planted or potted. To my right, are stairsteps covered with caladiums, of many different varieties. I wish I could list each species by name, but I can say with certainty that all their leaves come in a magnificent array of colors, with each leaf shaped like an elongated heart. Some are a dusty red, with green borders, and some are green with red trim. Some have green veins running though reds, whereas others are white, with green stripes, and so on. There are so many permutations to these shade flowers, and so many variations—but they share one thing—they need shade and may wither and die in full sun.

A few feet above those stair steps sits a balcony, surrounded by white fencing, some of which remains in the shade, and some of which continues into the sun. From those railings that rest above the caladiums hang scrolled wire baskets, filled with begonias. Some begonias are off-white, while others are pale pink, and yet more are coral or a deeper red that many might call vermillion. The colors and textures of the begonias play off the translucent shades of the caladiums below, although the shapes and sizes of the begonias are dramatically different from the large, elongated leaves of the caladium. But begonias and caladium have something in common: both prefer shade and cannot tolerate the sun.

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat.

If you will bear with me just a little bit more, let me mention one more garden, straight ahead of me, in full frontal view, shaded by towering pine trees that drop sticky pinecones each fall. By this time of the summer, the hostas are in full bloom, having grown wider and taller each year. They, too, come in many different hues, and many different varieties, even though each of them is some shade of green. A true horticulturist could name each and every one, but I am content to call each of them beautiful, with no need to know more for now. In the sweltering heat of summer, they sprout long stems with pale lilac flowers. In the early spring, those same rows are occupied by pink daffodils that also thrive in the shade, in contrast to their better-known cousins that demand full sun. I adore those sun-loving narcissi also, with their yellow and orange and gold trumpet-shaped crowns, and which proclaim the start of spring.

I could go on and on about each plant, shrub, and flower in my gardens, but let me explain why I am comparing plants to patients.

Patients Who Found Their Place in the Shade

As humans, we have the hubris to believe that we can change nature and impose our wills on biology (hurricanes, wildfires, and floods notwithstanding). Sometimes we can succeed at altering the course of nature, and often, we should—but not always. For sure, human-made irrigation systems made Israel’s deserts bloom, replacing sand with fruit trees to feed the population. Without surgical interventions, children born with club feet could be left with lifelong limps, unable to ambulate fully. And so on and so forth. Yes, modern medicine has worked miracles for many, often offering longer and healthier lives. But how does psychiatry fit into this picture and how does that impact psychopharmacology in particular?

While I applaud many advances in our field that help patients lead more productive and more pleasant lives, I sometimes think that we can help some even more by helping them find their own natural habitat—even if it is not an environment that is envied by others.

Let me provide 2 patient examples to dramatize this point. Let me call one “Ms A” and the other “Mr B.” Ms A was already an attorney, albeit one who hated reading and writing—and especially arguing. Yet she chose law on the advice of her parents, who dismissed her wish to become a baker, unmoved by the wonderful creations she made for friends and family. Ms A did well in grade school, high school, and college, well enough to be admitted to law school. Yet her concentration dropped as she studied legal details that held little interest for her. A local doctor diagnosed her with attention-deficit/hyperactivity disorder and started her on stimulants, despite the absence of an early history of attention problems, and apparently without inquiring about her interest in the subjects that she studied. With these pharmaceutical aids, she earned her JD, passed the bar, and was hired by a mid-sized law firm in midtown Manhattan. Although her parents were thrilled by her seeming success, (her analogue to a garden’s sunshine), she was unhappy sitting at a desk, staring at a computer screen, when she wanted to be baking.

Because she was so unhappy, she went to each happy hour after work, and soon enough developed an alcohol use disorder. She started coming in late for work when she was not calling in sick. Luckily, the bar association offered help to their members and referred her to treatment, which by this time included antidepressants as well as anti-craving medications. We also added behavioral activation to encourage her to engage in pleasurable activities (and to increase the odds of overcoming depression, as reported in 

Instead of idling away her after-work hours at local watering holes, she signed up for culinary classes. Her mood brightened enough, and her concentration cleared enough, for her to decide on her own to complete a culinary certificate and to change careers. As she put it, she preferred to “knead dough” rather than to make more dough. No longer sitting in a chair for hours on end, she could wander around a commercial kitchen at will. She decided that she no longer needed the stimulants that were prescribed to push her through an education that she disdained. In short, she found her shade garden where she could not just survive, but thrive—even if it was not the sunny rose garden that her parents recommended.

Mr B’s situation was somewhat different. Always a shy man, Mr B found solace in his college computer classes that required limited human interaction—and that also promised a bright financial future. It came as no surprise that he landed a good-paying coding job after graduation, but it was an unpleasant surprise when he became paranoid while working in a large open space rather than a confined cubicle. Soon enough, he accused coworkers of plotting against him, and engaged in enough arguments to lose the job. He never had frank auditory hallucinations—only barely audible intermittent whispers—but, in hindsight, his evolving symptoms sounded ominous. It was easy enough to find another job, given his high-level coding skills and the high demand for such skills, and it was surprisingly easy to squash those emerging psychiatric symptoms with a low dose of an atypical antipsychotic.

All might have worked well, had he not developed involuntary facial twitches from his new medication. To avert worse consequences in the future, he reluctantly agreed to stop the medication, even though it had brought him so much relief. We substituted cognitive behavioral therapy techniques instead, and watchful waiting. Then, Mr B was literally saved by the pandemic. Everyone in his office was forced to work from home. Without the untenable proximity to his coworkers, his paranoid symptoms abated, even in the absence of medication. The erratic whispers evaporated. Even his productivity improved, and his supervisor commended him. When the company owners spoke about reopening the office, we opted to request accommodation under the Americans with Disabilities Act, which would allow him to work from his family’s home. Better to work from home than to wind up in a hospital setting, should his rudimentary symptoms return and progress to a full-blown schizophrenic break, which could impair his cognition in the future and interfere with his employability. For Mr B, his home office was his shade garden, where he could survive and thrive.

Is there a moral to this story and a special message to psychiatrists? Yes, there is. These 2 cases of 

 demonstrate the interactions between humans and their environments.

I wish I could claim to have discovered the concept of human ecology, but I cannot. This term was coined many decades earlier. Although we discuss the impact of climate change on human well-being, human ecology is not a concept that we typically discuss in contemporary psychiatry, but perhaps this concept deserves consideration. The concept of human ecology traces back to Carl Linnaeus, MD, whose name we heard in those biology and botany premedical courses taken while we were 

 to becoming physicians. Linnaeus is best remembered as a taxonomist who categorized both animals and plants—but he was much more than that. Linnaeus was both a botanist and a physician who probably would have appreciated how gazing at gardens can add insights into treating patients.

is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. Park LT, Zarate CA Jr. Depression in the primary care setting. 

Different flowers need different levels of light, water, and shade. What would it mean to treat patients with a similar amount of care? 

Lessons From my Garden About Patient Care

FIRST MAN: We should defend ourselves. An eye for an eye, a tooth for a tooth.

TEVYE: Very good. And that way, the whole world will be blind and toothless.

- From 1970 script of the play “Fiddler on the Roof” and often attributed to Mohandas Gandhi

“The three ingredients for healing relational wounds are safety, truth, and reconciliation, and in that order.” - Alisha Moreland-Capuia, MD

Achieving peace in the Middle East is a monumental task that seems to be ever evasive, daunting, and out of reach. A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace. The violence is also spilling over into increased conflict between groups in the United States. Muslims and Jews are subject to worrisome degrees of Islamophobia and Anti-Semitism. The Palestinian-Israeli conflict is an extremely complex tangle of issues to resolve, but a solution is possible, and imperative.

Both sides and their supporters need to abandon ultimately futile and self-defeating acts of violence and retaliation. Instead, they must embrace a more comprehensive and humble vision that takes into consideration the historical, geographic, religious, and cultural context of two cousin tribes that have wounded each other over generations. It is like a longstanding family conflict in which family members stop talking to one another and replace talking with hatred, necessitating therapeutic family interventions. Despite the reservations that some psychiatrists have on entering the social conflict sphere, these are, in fact, areas of psychiatric expertise.

As psychiatrists we know group dynamics. We know our tendency to scapegoat “the other”. We know how the powerful can divide and conquer less powerful groups. We know how to analyze leaders. We know the temporary but necessary pain of revealing and processing the truth. We know from Abraham Maslow, PhD’s pyramid of psychological needs that safety and security must be fulfilled before higher levels needs can be completed. We know that often deeper levels of traumatic causation need to be processed and dealt with before healing can meaningfully occur.

This is not a naive proposal by any means, though it may seem so to some. Inevitably, many will disagree with any Middle East analysis. Rather, it is a plea for change because doing the same thing over and over again, expecting different results, is the very definition of insanity. Constantly suspecting each other’s motives has not moved this protracted struggle even an inch out of square zero. As good as prior endeavors were—that is, things could have gotten even worse—they have not been nearly enough.

There are many intricate political and psychosocial dynamics that come into play to make this mission look impossible; however, fighting parties in other parts of the world have managed, for the sake of their children, to reach some kind of compromise that benefits all involved. Children in the blessed land should not continue to pay the price of our ignorance, false pride, and generational bigotry.

As Muslim, Jewish, Christian, Hindu, and Sikh psychiatrists, in a bio-psycho-social-spiritual model we sense this is a moral and spiritual crisis. We support peace among nations, safe and secure homelands, and opportunities for all. This is not at its essence a fight between Muslims and Jews, or between Arabs and Israelis. This is an ideological and practical war that often intentionally feeds cultish misinformation, especially via the internet, which artificially arouses emotions, leading to relieving emotional tension by ever-increasing violence. Peace-loving civilians lose their lives, while extremist groups and fear mongers run rampant.

Unfortunately, the media usually chooses to focus on the negative events occurring in the Palestinian-Israeli conflict, and ignores equally dispiriting, yet equally important, inter-ethnic tragedies taking place in places like Kashmir, Myanmar, China, Syria, Yemen, Iraq, and elsewhere around the globe. This disproportionate attention to one particular locale in the Middle East only enflames matters more. It leads the public to believe that this is a unique situation, when it is a tendency of human nature that needs to be overcome everywhere. Despite our paradoxically doing so in this paper, we include other examples and intend to address them more in the future.

Perhaps we can learn and apply a few lessons from countries like South Africa, Rwanda, and Bosnia, where warring tribes have seemingly learned to live together. The Truth and Reconciliation Commission was especially effective in helping to bring South Africa out of apartheid without a bloodbath. 

Big problems get resolved only when broken down into small pieces. The use of dialogue can—and should—start in our households, small intra- and inter-faith circles, and cultural communities. A group of international and interfaith psychiatric caregivers have come together to create a community of care and have produced two requested, well-reviewed books that can be used as tools towards healing: 

From these sources, here are some ideal prescriptions to start with:

- Dignity for all, established by working together respectfully for a common end

- Humiliation for none, which means hearing each other out

- Apologies by all, as saying “I’m sorry” and meaning it begins the healing of many wounds

- Gifts to the others, such as sharing assets and promoting each other’s strengths

- Neutral peace-maker(s), or the calling in of trusted third parties, which may ideally need to include mental health experts

- Teaching tolerance to children, both by parents and educators

- Addressing intergenerational trauma, which includes that affecting political decision-makers

Also, as psychiatrists, we know very well that an illness cannot be cured unless we address its root causes, and similarly we have the moral obligation to call for the immediate dismantling of bigoted and violent ideologies, dictatorships, and all structures and systems that support them. They are so damaging to the body, mind, heart, soul, and spirit of so many of the people.

These are simple, though not simplistic, aspirational goals. They are meant as an antidote to the common lament about how complex these situations are, so often leading to excuses about what cannot be done and what cannot be tried. Prayer and mourning must be supplemented with action.

We need a few small steps in addition to this manifesto. Some that could be taken by SPIRIT and like-minded groups include: joint business projects, a student exchange, common textbooks (especially in the early grades), shared vacation spots, media consultation, and joint research. We must look towards innovative and out-of-the-box solutions.

Members of SPIRIT are available for consultation and discussion. We welcome other like- hearted psychiatrists of any religious background, as well as those who are agnostic or atheist, to join our SPIRIT.

is practicing psychiatrist in Providence Healthcare System, Portland, OR. He has provided psychiatric and humanistic care to trauma survivors around the world.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

is Clinical Professor and Chair of Psychiatry and Behavioral Science at the University of North Dakota School of Medicine and Health Sciences.

is an associate professor of psychiatry at Harvard Medical School and a Fellowship Site Director for Brigham and Women's Hospital.

is Professor Emerita, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.

is a Professor of Psychiatry at Cooper Medical School of Rowan University. He is active in several national and regional organizations and published and presented on International Medical graduates, culture, religion, family psychiatry, gender issues, etc.

serves as Assistant Dean of Clinical Education at Charles R. Drew University and Chief Medical Officer of Kedren Health Systems Inc.

is Medical Director of Child and Adolescent Psychiatry Clinic and Multidisciplinary Autism Program at ChristianaCare, Delaware.

is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai, New York, NY.

is a psychiatrist, the author of more than 300 peer reviewed papers, founder of Critica, and board member of the Social venture Fund for Arab Jewish Equality in Israel.

is Professor Emeritus in Psychiatry at the University of California at San Diego, as well as the author of more than 100 professional articles and 6 books.

interested in exploring the intersection between childhood political trauma with immigration stress. She has been recently offered a full-time research appointment as a Visiting Researcher at Harvard University, in Cambridge, Boston.

is a doctor working in frontline psychiatry for the National Health Service at South London and Maudsley NHS Foundation Trust in the UK.

is a Clinical Associate Professor of psychiatry at the Stanford University School of Medicine where she is the Director of the Stanford Muslim Mental Health & Islamic Psychology Lab, and the Director of its community organization: Maristan.org. She also serves as the Associate Division Chief for Public Mental Health and Population Sciences as well as the Section Chief of Diversity and Cultural Mental Health in the Department of Psychiatry and Stanford.

1. Moffic HS, Peteet J, Hankir A, Awaad R. 

https://www.springer.com/gp/book/9783030005115

2. Moffic HS, Peteet J, Hankir A, Seeman, M. 

https://www.springer.com/gp/book/9783030377441

A cease fire is welcome, but a far cry from what we want to achieve—lasting Middle East peace.