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“I cannot bear the thought of one more practitioner telling me they think they have the answer for me,” said “Molly” during a particularly difficult session when we were talking about her chronic low mood, pain, and difficulty sleeping. What she meant was that after hearing so many people say, in so many different ways, that they believed they could help her, she was learning and becoming overwhelmed by all of the things within her that did not work. Her nervous system, her diet, her sleep habits, her neurotransmitters, her thoughts, her ability to emotionally regulate … all of it was “broken.”

It was so difficult to watch Molly continue to suffer. The part of me shaped by solution-focused and efficient care wanted to jump up and say, “but have you tried X, Y, and Z?” Instead, I called on curiosity and attunement. I slowed down, and we talked about her frustration and her hopelessness. About how, although her team—myself included—all meant well, we were making it worse. About how, with every “solution” that 

 came another wave of believing she was unfixable. I saw hope begin to regrow as we sat through the pain of the hopelessness. We started talking about what should happen next (because honestly, even the best-laid plans still often need some level of goal setting), but this time, the conversation was different. I was looking to her to tell me what she needed from her entire team. I was asking her what she needed 

I may not have had the answer that would solve all her ailments, but I did have the knowledge and ability to share with her team what I believed she needed from us: a willingness to reach a common goal and a common belief in her ability to heal. I was lucky enough to be working alongside practitioners who were willing to slow down and step away from having the answer. Rather than seeking information that validated our professional opinions, we sought to listen to the ways the client was 

 her therapeutic experience with each of us (and I mean that in the sense of her entire being, not simply her mental health).

I would love to say that within months all this client’s symptoms miraculously improved, but in all honesty, we are still all actively working to help get her to where she wants to be. What did change, though, was the client’s belief she had in herself and her hope that things would improve. When a person believes in their ability to heal and feels they have an honest stake in their treatment, they are more likely to engage in their own care, thus improving treatment outcomes.

 With Molly, it was the shift to focusing on her experiences within relationships with her team that allowed this to happen.

Sue Johnson, EdD, a researcher and clinician who has taken Bowlby’s attachment theory and molded it into Emotionally Focused Therapy, one of the most well-researched relational modalities of today,

 elaborates on Bowlby’s belief that “the human psyche, like human bones, is strongly inclined towards self-healing.”

 She shares that although this is true, it is validation and an environment that feels safe that allows this healing to actually take place.

 Similarly, Deb Dana’s application of polyvagal theory to clinical settings has shown that providing emotional connection and safety for our clients means improved physiological and psychological health outcomes.

Unfortunately, as the third, fourth, and now fifth waves of therapy have studied and encouraged this importance of relationship and safety to promote healing, the systems that push for efficient and solution-focused care have put pressures on us to do the very opposite. These systems put pressure on us as providers to have answers as quickly as possible, and do not leave time for honest inquiry or dialogue. This means little to no opportunity to explore beyond measurable outcomes and desired goals, or to talk with the client’s other team members about how they experience this client, their areas of struggle, or their hopes for the client’s healing. It means that even with the best of intention, the relational experience often stops at the door.

Typically, when a client leaves our office, we have little to no control over what they do with their time and our recommendations after or between sessions. Although our clinical opinion is likely well-thought-out and offered with the intention of encouraging growth and change, the exchange of information can only go so far. The current system of care encourages clients to come to us because of our knowledge, skillset, and the answers we have for them—answers that we hope will lessen their pain and enhance their ability to live the life they want to live. Unfortunately, it is the idea that we, as the mental health providers, have all the answers that can hinder the development of relationships necessary for meaningful healing, thus impacting effectiveness of support.

A New Approach: Relationally Focused Care

In Molly’s case, it was both my responsibility to share my knowledge and the responsibility of my team members to value my knowledge as we navigated this case. This exchange, in practice, models and encourages a similar exchange in our clients. It provides them with the opportunity to learn to believe in themselves and in their team. Emphasis on the relationships between providers, between providers and clients, within clients themselves, and between the entire team and the community is referred to as relationship-centered care (RCC), which conceptualizes health care by the quality of these relationships.

 The 4 principles of RCC go beyond the technicalities of providing care and can be seen in the 

Even in settings in which there may be opportunity for RCC, emphasis on measurable outcomes can hinder collective conversation. Data obtained as part of an action research study aiming to understand the way professionals navigate discord and decision-making in a team-based format highlights these hindrances.

 The study showed that socioemotional concerns are introduced to team discussion far less frequently than task-oriented concerns, thus limiting cross-discussion between disciplines and even among mental health team members.

 Here we see, once more, the necessity of valuing and making space for conversation and exploration over efficiency.

Commitment to relationally focused care opens the door for us to move beyond the confines of efficiency and into “a state of connection [where] health, growth, and restoration are possible.”

 When it comes to supporting our clients, I believe it is our job, as practitioners and team members, to create an environment and experience that encourages our clients to make the choices that will improve their overall health and healing, mirroring the very environments and experiences Johnson and Dana write about. In order to do this, we have to believe that our clients are more than a system of pulleys and chains—we have to believe that they are one integrated system, thus requiring relationally oriented and integrated care.

When clients come to us, as the experts, looking for answers, we too can be fooled by the expectation that we should be able to give it to them. I believe, as the professional in the room, it is up to us to model for our clients that their whole story and experience with us in the moment matters, not just the measurable outcomes. In order for this to happen, we need to begin to move away from the idea that we, as any particular type of practitioner, are the best, most knowledgeable, or only option. This means valuing our role while also valuing the roles and knowledge of others. John Shotter discusses the danger of generalizability, which he defines as “continual rediscovery of sameness.”

 He posits that as soon as we place a label on someone, it narrows what we have the ability to discover and thus help to heal that person.

 In a field in which we are encouraged to silo, to find a specialty, we are ripe to fall into this risk of generalizability.

 If instead we permit ourselves, and encourage one another, to remain open to the answers, we open ourselves up to endless options for potential healing for our clients.

As a therapist who focuses much of her work on complex trauma, I am no stranger to the pull to have an answer for a client in pain. I also fall victim to the pressure to fix. Sometimes it takes the honesty of a client’s experience to remind us of the bigger picture, and that is exactly what happened with Molly.

The Search for Answers and the Collaborative Process

Whether we are talking about changing the way we collaborate individually with our clients, with our colleagues, or with the team supporting our clients, perhaps the place we ought to begin is with ourselves. Understanding what drives us to seek answers instead of exploration, be it societal, cultural, or internal forces, is a necessary step toward RCC. Becoming aware of our own relational tendencies can help navigate intentionally toward connection. Becoming self-informed through tools like 

The Attachment Project’s Attachment Quiz

 Beyond understanding ourselves, we can start to get curious about our colleagues’ experiences, all in an effort to prioritize relationship.

The evidence is clear that relationship, dialogue, and connection affect patient experience,

 and the more positive the experience, the more likely treatment is to have the desired effects of healing, growth, and change.

 RCC contributes to the development of a safe environment, encourages open dialogue, and creates a shared experience of goal development and attainment.

 The idea that we as practitioners should be able to cure or heal our clients by ourselves is an outdated and limiting model of treatment. If we do the work to understand our own selves relationally, and the beliefs that may contribute to our own need for success, we provide an opportunity to shift the focus to where it belongs: on the relationship. We need one another, and our clients need us to model connection and belief in one another so that they can believe in the possibility of their healing.

is a licensed independent clinical social worker in the state of New Hampshire and a therapist and owner of Soul’s Nest Counseling & Wellness LLC.

Polyvagal Exercises for Safety and Connection: 50 Client-Centered Practices

Attachment theory and emotionally focused therapy for individuals and couples: perfect partners

Attachment Theory and Research in Clinical Work With Adults

4. Beach MC, Inui T; Relationship-Centered Care Research Network. 

Relationship-centered care. A constructive reframing

The somatically preoccupied patient in primary care: use of attachment theory to strengthen physician-patient relationships

Do all health and social care professionals interact equally: a study of interactions in multidisciplinary teams in the United Kingdom

Goethe and the refiguring of intellectual inquiry: from “aboutness”-thinking to “withness”-thinking in everyday life

More than cool reason: “withness-thinking” or “systemic-thinking” and “thinking 

Collaborative-dialogue based research as everyday practice: questioning our myths

Systemic Inquiry: Innovation in Reflexive Practice Research. Everything is Connected Press

. The Attachment Project. Accessed December 1, 2021.

How can a refocus on relationships, connections, and dialogue improve the overall patient experience?

Collaborative Care: The Team as a Social-Relational Healing Tool

Adolf Meyer, MD, the preeminent American psychiatrist during the first half of the 20th century, served as the inaugural director of The Henry Phipps Psychiatric Clinic at Johns Hopkins Hospital for 30 years. Meyer recognized that patients experiencing psychiatric problems often have signs and symptoms found in more than 1 psychiatric condition, which limits the clinical utility of a categorical approach to psychiatric formulation. He instead conceptualized mental disorders as emerging from the brain in interaction with the complex lives of individual patients. This understanding of psychiatric illness informed Meyer’s comprehensive approach to the examination of patients, with its remarkably detailed longitudinal history necessary for understanding the full and personal context of a patient’s distress. It became the standard for American psychiatrists, as well as those in Britain and parts of Asia and Europe, for decades.

The German-Swiss psychiatrist Karl Jaspers, MD, also emphasized the role of a longitudinal history in the psychiatric examination of patients. In addition, Jaspers stressed the importance of using multiple conceptual frameworks in the formulation of an individual patient, while considering the strengths and limitations of each framework.

Contrast the personalized approach of Meyer and Jaspers with the practice of psychiatry in the 21st century, guided by the DSM. Although the DSM has allowed researchers to study—sometimes reliably—similar groups of patients, its method of assigning diagnoses based on various, nonspecific signs and symptoms remains problematic.

 The DSM, by implying a categorical approach to diagnosis, de-emphasizes the core of Meyer and Jaspers’ approaches: that a disorder of mental life and behavior does not occur in a vacuum, but is always embedded in the life and identity of an individual patient.

Paul McHugh, MD, one of Meyer’s successors as chief of psychiatry at Johns Hopkins, discovered the writings of Meyer and Jaspers, and, drawing on their work, he began teaching US psychiatry residents a similar comprehensive and personalized approach to examining patients. He articulated this in a book he cowrote with Phillip Slavney, MD: 

 For nearly half a century, Hopkins psychiatrists have been trained to use the Perspectives approach as an organizing framework for the practical and personalized care of patients. At its core, the Perspectives approach recognizes that the problems for which people seek psychiatric care have a variety of natures and origins, and, unlike the rest of medicine, not all are best explained as diseases. The origins of psychiatric problems vary from the explanations of genetics and neuroscience to the understandings of Freud and Jung.

There are 4 perspectives, which can be recalled by the acronym, HIDE:

Given the complex nature of humans as embodied selves, psychiatrists must look at patients from all 4 perspectives to develop a holistic formulation and personalized treatment plan. For most patients, more than 1 of these perspectives is relevant to the problem for which they are seeking help.

The disease perspective says some psychiatric problems are simply due to the breakdown of the brain or a metabolic process, in the same way that any disease in the body might arise. A disease is something that a patient 

—like delirium or schizophrenia. Its underlying conceptual triad is clinical syndrome, pathophysiologic process, and etiology, and the goal of treatment is remedying or curing the broken part or function.

The dimensional perspective recognizes that people differ in their cognitive powers and affective temperaments. This perspective is concerned with who a patient 

—the patient’s personality. Its conceptual triad is potential, provocation, and response, and the goal of treatment is to help patients understand their personalities and guide them to different cognitive and behavioral responses.

The behavior perspective notes that some people are troubled because of what they are 

—for instance, restricting their food intake or using drugs. Its conceptual triad is drive (either innate or acquired), conditioned learning, and choice, and the goal of treatment is to interrupt the problematic behavior.

The life story perspective—the most personal perspective—highlights how some patients are in distress because of what they have 

—like sexual assault or the loss of a loved one—and how they have dealt with and thought about those events. Its conceptual triad is that of any narrative—setting, sequence, and outcome—and the goal of treatment is to help rescript a patient to a more adaptive story.

In addition to helping patients recover from their acute problems, clinicians must be concerned with helping them stay well and lead a good life. Tyler VanderWeele, an epidemiologist from Harvard University, recently developed a model and measure to assess human flourishing. It includes the constructs of happiness and life satisfaction, close social relationships, physical and mental health, meaning and purpose, character and virtue, and financial/material security/stability. Using large, longitudinal data sets, he also identified 4 pathways causally linked to flourishing outcomes: family, community, work, and education.

Understanding where patients are on each of these flourishing pathways will allow clinicians to help patients stay well and reach their fullest potential.

This becomes especially clear when treating patients with addiction. At the Hopkins Center for Addiction and Pregnancy, where I worked for a decade, it was relatively easy to motivate women to stop using drugs during pregnancy, but keeping them well—especially postpartum—was often a challenge. Many had burned bridges with their families and limited their community to other users, were not employed, and had not achieved their education goals. I worked to help them rebuild their relationships with family, join support communities like AA or NA or reconnect with their faith community, and pursue work or a degree.

It is my hope that more and more clinicians will join me in putting the person back into psychiatry, and familiarize themselves with the 

and the pathways to human flourishing. With a comprehensive examination of every patient and thoughtful consideration of their problems from each of the 4 perspectives and flourishing pathways, we can help everyone experiencing a mental illness not only survive, but thrive.

 is a professor of psychiatry and behavioral sciences at the Johns Hopkins University. Board-certified in both general psychiatry and addiction medicine, she is the author of a new book for patients and their families: 

From Survive to Thrive: Living Your Best Life with Mental Illness

 (The Johns Hopkins University Press, 2021). Dr Chisolm is also director of the Paul McHugh Program for Human Flourishing, through which her work is supported.

Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry

First ed. The Johns Hopkins University Press; 2014.

One hundred years of psychiatry at Johns Hopkins: a story of Meyer to McHugh

Existence and pluralism: the rediscovery of Karl Jaspers

Striving for coherence: psychiatry’s efforts over classification

Mental illness—comprehensive evaluation or checklist?

Second ed. The Johns Hopkins University Press; 1998.

How can you use the 4 perspectives and 4 pathways to flourishing for practical and personalized patient care?

Putting the Person Back Into Psychiatry

The word, mindfulness, has its origins in the Sanskrit 

, which refers to awareness, attention, or alertness, and 

, which means insight cultivated by meditation. An ancient Buddhist practice, mindfulness gained acceptance in traditional Western medicine and society in the 1970s through the work of Jon Kabat-Zinn.

Considered the “master of mindfulness,” Kabat-Zinn defines mindfulness as “an awareness that emerges through paying attention on purpose, in the present moment and non-judgmentally, to the unfolding of experience moment by moment.”

 This definition highlights the 3 tenets of mindfulness: 1) give undivided attention; 2) be aware of present thoughts and emotions; 3) accept them without judgment. Elements of mindfulness are incorporated commonly in practices such as yoga, meditation, relaxation, and breathing exercises,

 all of which are focused on grounding and directing and redirecting attention, with the goal of achieving harmony between the mind, the body, and the environment for improved health outcomes. Mindfulness can be practiced anytime, anywhere, and by anyone through full engagement in the here and now.

Self-reported instruments/questionnaires are often used to assess mindfulness as: 1) a single-factor trait (eg, the Mindful Attention Awareness Scale) or state construct (eg, the Toronto Mindfulness Scale), or 2) a multi-construct concept with subscales capturing skills/tenets of mindfulness (eg, the Kentucky Inventory of Mindfulness Skills) or underlying coping processes (eg, the Applied Mindfulness Process Scale). Operationalization of mindfulness, especially when using multi-construct instruments, is important in that it allows exploration of underlying mechanisms of action, which helps inform the design of psychotherapeutic approaches and mindfulness-based interventions (eg, improve positive emotional regulation) to better increase effectiveness of treatment by focusing on components responsible for treatment effects.

Clinical Value and Cognitive Aspects of Baseline Mindfulness

Understanding the benefits of mindfulness in psychiatric patient populations is important, as it offers clinicians a nonpharmacological therapeutic venue to address mental health issues deriving from living with chronic psychiatric, psychological, or neurological conditions, or from providing care to someone with these conditions such as Alzheimer disease and related dementias (ADRD), depression, or social anxiety. Determining patients’ baseline mindfulness facilitates identification of those most likely to benefit from mindfulness-based interventions to improve psychological outcomes, and it helps mental health providers better understand how patients may respond to treatment. In addition, baseline mindfulness may help providers better understand patterns of patients self-reporting their symptoms, or how they perform on cognitive and psychological testing during the initial office visit.

 In patients with ADRD, for example, higher baseline mindfulness predicts better cognitive performance and less severe cognitive impairment, likely via better positive emotional regulation, greater engagement in brain-protective behaviors such as physical activity and socialization, lower frailty, and cardiovascular risk, and greater resilience.

Mindfulness has been consistently linked to psychosocial outcomes including higher life satisfaction, lower depression, dissociation, social anxiety, and rumination, and better cognitive processes such as lower frequency of negative automatic thoughts, with important implications for psychological health.

 Finally, regular engagement in mindfulness practice is positively linked to psychological well-being, cognitive flexibility, and attentional functioning and negatively associated with psychological symptoms including rumination, thought suppression, and difficulties with emotion regulation.

 Thus, understanding and applying aspects of mindfulness during patient evaluations provides another useful tool for practicing psychiatrists and other mental health providers.

The observed link with psychological and other health outcomes led to the development of several mindfulness-based therapies to address these health concerns. Mindfulness-based stress reduction (MBSR), the first therapeutic modality championed by Kabat-Zinn in the 80s and 90s for treatment of patients with chronic pain, is an 8- to 10-week group program engaging participants in mindfulness meditation training and practice with the goal of becoming less reactive, more acceptant of their own experiences, and more able to disengage from maladaptive behaviors and thoughts and to reduce negative experiences through cognitive reappraisal.

Mindfulness-based cognitive therapy (MBCT) was developed for the treatment of remitted depression and combines mindfulness training with elements of cognitive therapy with the goal of changing awareness of and relationship to thoughts and emotions

 and “breaking” the association between negative automatic thinking and dysphoria.

 Dialectical behavior therapy (DBT), first developed as a treatment for chronic suicidality, integrates elements of traditional cognitive-based therapy (CBT), Zen practice, and mindfulness skill training to improve emotional regulation and increase patient self-acceptance through a combination of behavior change (CBT), acceptance-oriented (Zen) strategies, and coping skill training (mindfulness).

Benefits of Mindfulness-Based Interventions

The robust positive relationships observed in observational studies between mindfulness and various psychological and cognitive outcomes are supported by reports from mindfulness-based interventions (

). There is consistent evidence for a positive effect of MBSR on mood (reduced anxiety and depression), stress (reduced distress), cognition (improved performance), and overall wellbeing (improved satisfaction with life and quality of life) in nonclinical (eg, students, community-dwelling adults, health care professionals) and clinical (eg, patients with fibromyalgia, cancer, social anxiety, bipolar disorder, and neurological conditions) populations.

 These findings are further supported by observed brain changes in areas associated with emotional regulation in participants receiving MBSR compared to controls.

Initial studies of MBCT in patients with major depression found compelling evidence for reductions in relapse rates in those receiving MBCT interventions,

 reductions that may be similar to what is observed in patients on pharmacotherapy, with effects significantly improved when the 2 are combined.

 Despite this evidence, pharmacotherapy remains the main treatment option for many patients with mental disorders, although ~75% of patients with mental disorders prefer psychotherapy.

More recently, clinical trials on MBCT have expanded their investigation into other psychosocial outcomes, reporting benefits on anxiety, depressive mood, quality of life, symptoms of social phobia, cognition, metacognitive awareness, and thought suppression in patients with recurrent depression,

 as well as other psychiatric conditions including suicidal ideation or behavior, bipolar depression, social phobia, and epilepsy.

 Imaging studies confirmed increased activation following MBCT in brain areas such as the medial prefrontal cortex, which is involved in emotional processing and self-referential mental activities.

Similarly, DBT therapy has been found to be successful in reducing suicidal ideation and behavior and self-harm behavior including drug use, self-mutilation, and binge-eating in patients with borderline personality behavior,

 comorbid substance dependence, bulimia, depression,

 and more recently in patients with attention-deficit/hyperactivity disorder.

 Benefits on other psychological outcomes include reduced depression, anxiety, hopelessness, dissociation, anger, and improved global social adjustment and functioning, and adaptive coping.

 Providing further evidence for an impact of DBT on psychological outcomes, pre-post intervention changes in the brain including reduction in amygdala activation

 and alteration of grey matter in regions of the brain that are implicated in emotion regulation and higher-order functions following DBT were reported in patients with borderline personality disorder.

Finally, mindfulness-based interventions have been found to improve cognitive and psychosocial outcomes in patients with ADRD and their caregivers, who both suffer from increased stress, depression, anxiety, and burden either from having the disease or from providing care for someone with the disease, with further negative impact on health and wellbeing. The evidence is consistent in showing that older adults with ADRD participating in MBI have improved cognitive function

 and psychosocial functioning including depressive and anxious symptomatology and perceived stress.

 Mindfulness-based interventions in individuals who provide round-the-clock care to patients with ADRD were shown to produce improvements in stress, burden, mood, and quality of life.

 When done simultaneously in patients and caregivers, mindfulness-based interventions are successful at improving mood and quality of life in both, supporting a crossover of effects from caregivers to patients.

George is a 70-year-old retired educator who sought therapy for depression and anxiety related to a 2018 diagnosis of ADRD. The diagnostic interview indicated that he suffers from depression and anxiety due to another medical condition according to the DSM-V. During the initial session, George complained about increased apathy, a feeling of despair, and a struggle to find meaning in the time he has left. He reported a constant worry surrounding a gradual loss of cognitive function impeding his ability to drive, sleep, and participate in activities he used to enjoy including long-distance bike riding.

Goals of treatment included use of mindfulness-based modalities (MBSR, DBT, and MBCT) to:

-Increase insight of depressive and anxious feelings.

-Teach George to identify automatic negative thoughts (ANTS) and learn to reframe them.

-Improve problem solving concerning return to physical activities he enjoys.

-Meditation: George participated in short meditations specifically targeting awareness of feelings and anxiety reduction, gradually increasing insight, and understanding of his feelings and emotions.

-Reframing ANTS:  Recording situations preceding ANTS eventually taught George to fact-check the dysfunctional thoughts and challenge their validity.

-Journaling: George journaled his struggle with acceptance of the disease, including moments of gratefulness he encountered throughout his week.

-Setting intention: George learned to set an intention every morning, checking in with himself throughout the day to course correct so he can stay on target.

George was open-minded and cooperative with the treatment, and the therapeutic results were remarkable. After a month of weekly sessions, George resumed his long-distance bike rides and other physical actives he enjoys. At the 3-month mark, he accepted his inability to drive and surrendered his driver’s license to his wife. After 10 months of mindfulness-based therapy, he sleeps well throughout the night, looks forward to meaningful interactions with his family and friends, and reports having “APTS: automatic positive thoughts” (his own term), as opposed to ANTS. He set alarms on his phone to “jump for joy” in the morning and to “be grateful” in the afternoon.

There is compelling evidence to support mindfulness-based intervention as an effective treatment option in psychiatric patients either on its own or in combination with psychiatric medications. Psychotherapeutic approaches are found to be efficacious in a variety of psychiatric disorders and can address a multitude of psychosocial and cognitive challenges that are common in this patient population. Treatment decisions should take into consideration the patient’s baseline mindfulness, which can be easily assessed in the clinical setting, to determine which patients are likely to benefit from mindfulness and other therapies or to inform the clinician on patterns of response to treatment. Patients suffering from chronic conditions and those providing care to them respond well to psychotherapy and are reported to prefer it to pharmacotherapy.

Integration of nonpharmacological mindfulness-based treatment options that are backed by robust evidence of effectiveness in reducing anxiety, depression, stress, and burden, and in improving quality of life offers patients effective therapies that are generally considered safer and have fewer side effects. In addition, in the subset of psychiatric patients with cognitive impairment, mindfulness-based therapies may help maintain or even improve cognitive function, therefore addressing a significant public health concern in the geriatric population.

is a research assistant professor and associate director of research at the Comprehensive Center for Brain Health, Cognitive Disorders Division, University of Miami Miller School of Medicine. 

 is a social worker and community outreach coordinator in the Comprehensive Center for Brain Health, University of Miami Miller School of Medicine. 

is a professor of neurology at the University of Miami Miller School of Medicine and founding director of the Comprehensive Center for Brain Health.

This study was supported by grants to JEG from the National Institute on Aging (R01 AG071514, R01 AG069765, R01 AG057681, and R01 NS101483), the Harry T. Mangurian Foundation, and the Leo and Anne Albert Charitable Trust. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results

Potential benefits of mindfulness-based interventions in mild cognitive impairment and Alzheimer's disease: an interdisciplinary perspective

The effect of baseline patient and caregiver mindfulness on dementia outcomes

Effects of mindfulness on psychological health: a review of empirical studies

Psychological functioning in a sample of long-term practitioners of mindfulness meditation

7. Teasdale JD, Segal ZV, Williams JM, et al. 

Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy

8. Linehan MM, Korslund KE, Harned MS, et al. 

Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis

 [published correction appears in JAMA Psychiatry. 2015;72(9):951]. 

9. Koszycki D, Benger M, Shlik J, Bradwejn J. 

Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder

10. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. 

Alterations in brain and immune function produced by mindfulness meditation

Combined pharmacotherapy and psychotherapy in the treatment of mild to moderate major depression? 

12. McHugh RK, Whitton SW, Peckham AD, et al. 

Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review

13. Orgeta V, Qazi A, Spector A, Orrell M. 

Psychological treatments for depression and anxiety in dementia and mild cognitive impairment: systematic review and meta-analysis

14. Ives-Deliperi VL, Howells F, Stein DJ, et al. 

The effects of mindfulness-based cognitive therapy in patients with bipolar disorder: a controlled functional MRI investigation

15. Fleming AP, McMahon RJ, Moran LR, et al. 

Pilot randomized controlled trial of dialectical behavior therapy group skills training for ADHD among college students

16. Goodman M, Carpenter D, Tang CY, et al. 

Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder

17. Mancke F, Schmitt R, Winter D, et al. 

Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

18. Quintana-Hernández DJ, Miró-Barrachina MT, Ibáñez-Fernández IJ, et al. 

Mindfulness in the maintenance of cognitive capacities in Alzheimer’s disease: a randomized clinical trial

A systematic review of mindfulness-based interventions for patients with mild cognitive impairment or dementia and caregivers

 [published online ahead of print, 2020 Sep 16]. 

20. Paller KA, Creery JD, Florczak SM, et al. 

Benefits of mindfulness training for patients with progressive cognitive decline and their caregivers

How can mindfulness-based intervention be used as an effective treatment option for psychiatric patients?

The Effect of Mindfulness on Outcomes in Psychiatric Patients

Changing a single ingredient in the diet rarely makes a difference in studies of depression. 

, soy, and matcha tea have all been tried without success.

 Instead, nutritional psychiatry research has 

 the best antidepressant effects with a balanced, Mediterranean-style diet.

 But a small trial of almond supplementation in diabetes shows promise.

The study was a small, randomized controlled 

 of 45 Chinese adults with type-II diabetes.

 All of the subjects were counseled to adopt a low-fat diet that was rich in vegetables and protein and low in salt and carbohydrates. The control group was allowed a daily serving (300 grams) of a carbohydrate-rich food (in China, this was typically rice or noodles), while the intervention group cut that carb dish in half and replaced it with 56 grams of almonds (about half a cup).

After 3 months, those in the almond group had a significant reduction in depression on the self-reported PROMIS scale, while the average mood of the control group did not budge. The effect size was large (0.94 using Hedges’ correction for small sample sizes), although the statistical spread on that effect was wide (+/- 0.62). Importantly, the investigators did not require a diagnosis of depression to enter the trial. On average, their scores (49) fell just below the 55-point cut-off for mild depression on the 

, although some had moderate or severe depression (up to 81 on the PROMIS).

Metabolic parameters (weight and glycated hemoglobin (HbA1c)) improved significantly with both diets, although the reduction in HbA1c was larger (by 1 point) in the almond group (p < 0.01). Next, the investigators looked at changes in the gut microbiome to clarify the mechanism behind this antidepressant effect.

A diverse microbiome in the GI tract is associated with both metabolic and mental health. The gut bacteria 

 with the brain through multiple pathways, including the vagus nerve, inflammatory signaling, and short-chain fatty acids.

 microbiome diversity improved in both groups, but the almond group had a significant increase in bacterial species that produce short chain fatty acids (

). This type of bacteria stimulates production of the metabolic hormone glucagon-like peptide-1, which lowers appetite and regulates insulin. Supporting this hypothesis, levels of glucagon-like peptide-1 rose throughout the trial in the almond group.

is the Mood Disorders Section Editor for 

 He has written several books on mood disorders, most recently 

 with his co-host Kellie Newsome, PMH-NP.

The author does not accept honoraria from pharmaceutical companies but receives royalties from PESI for 

Effects of walnut consumption on mood in young adults-a randomized controlled trial.

2. Simpson EEA, Furlong ON, Parr HJ, et al. 

The effect of a randomized 12-week soy drink intervention on everyday mood in postmenopausal women.

3. Dietz C, Dekker M, Piqueras-Fiszman B. 

An intervention study on the effect of matcha tea, in drink and snack bar formats, on mood and cognitive performance

A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial).

A daily serving of almonds improved depressive symptoms in diabetes, but will it work in non-diabetic depression?

Integrative Psychiatry

Collaborative Care: The Team as a Social-Relational Healing Tool

Putting the Person Back Into Psychiatry

The Effect of Mindfulness on Outcomes in Psychiatric Patients

Almonds May Lift Depression in Diabetes

Top Treatment Modalities for Depression

Vital Amines: The Who, What, When, Where, Why, and How of Folate Deficiency

Can Food Treat Depression?

Positivism and Heart Health: Issues for Psychiatrists

Blueberries Treat Depression, With a Catch

Never Forget the Fine Print: From Fertility Rites to “Miracle Med”