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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

Paranoia, or fear of deliberate harm from others, is among the most common symptoms of schizophrenia-spectrum psychoses, and it also occurs in emotional disorders and other severe mental illnesses, placing 

 on the lives of patients and their families.

 Innovative therapeutic interventions are desperately needed to overcome paranoia and improve outcomes.

Existing therapies, whether pharmacological or psychotherapeutic, have widely recognized limitations in engagement, adherence, and effectiveness. Antipsychotic medication is the mainstay of treatment for most patients. However, distressing symptoms persist in 

 of those who take them, functional outcomes are frequently poor, and many discontinue treatment periodically or permanently, concerned about adverse effects, such as weight gain and metabolic syndrome.

 Psychological therapies, such as cognitive behavioral therapy for psychosis (CBTp), have been shown to improve psychotic symptoms, including paranoia, when added to treatment as usual in large clinical trials.

 But effects need to be improved, and implementation in routine care is poor. Individuals are often not willing or able to access and make use of therapy, particularly those from minoritized groups. There is a scarcity of trained therapists, with estimates suggesting only 0.3% of mental health consumers in the United States have access to CBTp.

A transformation in psychosis care is needed; digital technology has the potential to deliver it by improving the patient experience, therapy effectiveness, and 

 Digital interfaces can be designed to support personalization and accessibility, and they can assist engagement and adherence. Web and mobile technologies are also more readily scaled up than traditional interventions and can be designed to reduce training demands.

A New Frontier: Digital Therapeutics for Paranoia

To the best of our knowledge, metacognitive training (MCT), developed by Steffen Moritz, PhD, MSc, and colleagues, was the first psychological intervention for delusional beliefs that incorporated technology. It used desktop programming and presentation software to provide illustrative games and tasks. Group versions of this training approach were shown to have small to moderate effects on delusions, although it is important to note that patients with severe delusions were excluded and the basic digital materials were not personalized, limiting its ability to address challenges to therapy accessibility and adherence. More recently, individualized delivery of metacognitive therapy (MCT+) has been developed and evidence suggests it may have better effects on delusions, though there are only a few relatively

Building on this pioneering work, recent digital therapeutics for psychosis have sought to harness innovative technology such as virtual reality, social networking, mobile apps, and web-based therapies. Whilst preliminary findings are encouraging, few of these have been tested in large clinical trials, and those 

 In 1 of the largest trials to date, Depp et al (2019)

 investigated the effects of augmenting a single session of CBTp with an app, CBT2Go, compared to a single session of self-monitoring supported by an app or treatment as usual (TAU), in individuals with severe mental illness (N = 255). They found a small effect on general symptomatology favoring the CBT2Go and self-monitoring conditions over TAU. However, the impact on paranoia was not specifically examined, and the authors also note that baseline levels of psychosis symptoms were low. The FOCUS mobile app adopts a similar therapeutic approach, although it was investigated as a standalone app to support self-management in its most rigorous evaluation. Ben-Zeev et al (2019)

 compared FOCUS to a recovery group intervention in 163 patients with severe mental illness. They found no between-group differences on clinical outcomes, nor any within-group changes in psychosis symptoms.

These trials suggest that app-based technologies may safely and acceptably augment therapy for paranoia although, but they have yet to demonstrate meaningful clinical outcomes in robust designs. Crucially, there is little evidence that digital therapeutics have been designed to address healthcare inequalities. Indeed, emerging findings indicate digital therapies may actually exacerbate exclusion, with those from privileged demographic groups more likely to access and benefit from them.

In addressing the challenge of transforming psychosis care, we have developed SlowMo, an innovative digitally supported therapy for paranoia. SlowMo is based on the principles of CBTp and leverages technology to address health care inequalities, through enhancing therapy appeal and user friendliness for a 

 SlowMo therapy targets an evidence-based mechanism, or active ingredient, that we and others have shown can fuel paranoia.

 Drawing on the term popularized by Daniel Kahneman, PhD,

, comprising of a jumping to conclusions bias (forming rapid judgements using limited information) and belief inflexibility bias (reduced capacity for reflecting on one’s own beliefs, changing them in the light of new evidence, and considering alternatives). SlowMo is designed to help patients to slow down for a moment, encouraging awareness of a tendency to jump to conclusions and find new ways of feeling safer.

We followed human-centered design principles in the hopes of improving the user experience of therapy and radically enhancing engagement and adherence.

 Our multidisciplinary collaboration of individuals with lived experience, industrial designers, software developers, clinicians, and researchers developed SlowMo over 3 years through 7 cycles of prototyping. To address health care inequalities, we codesigned with stakeholders from diverse demographic backgrounds, who could identify therapy barriers and facilitators, and optimize the inclusivity of the design. SlowMo therapy consists of a web app delivered on a touchscreen laptop to support the delivery of face-to-face individual cognitive-behavioral therapy sessions, which is synchronized with a mobile app for use in daily life (

A Journey of Visualizing Thoughts and Thinking Habits

SlowMo uses new, responsive technologies to support the visualization of thoughts—as bubbles—and their associated thinking habits. This visual concept aims to enhance cognitive therapy by providing an appealing and tangible means of communicating subjective experience. The design minimizes the information processing demands, thereby lowering a significant barrier to engagement with traditional talking therapies. Patients interact with their personalized SlowMo thought bubbles using a touchscreen, altering speed, size, and transparency to reflect related thinking habits, distress, and conviction.

The SlowMo webapp used during sessions presents therapy as a journey, with interactive features including information, animated stories, and games. As well as tailoring worry and positive thought bubbles, patients record key learning points and future plans, with all content synchronized to the mobile phone app for access outside of sessions. The mobile app allows patients to notice their fears and thinking habits as they occur in daily life and helps them to find other ways of managing distressing experiences. It consists of a redesigned CBT thought record for managing paranoia and attempts to overcome the limitations of paper versions, which can be an inaccessible means of support during peak moments of distress. SlowMo uses a native mobile app with opt-in data transfer, addressing patients’ privacy concerns, which was a salient theme during the design research. The mobile app relies on user-initiated interaction and optional push notifications, to accommodate those who wish to have control over their data and find passive monitoring intrusive.

Delivering Evidence-Based Benefits for Recovery in Psychosis

SlowMo therapy has been iteratively developed over the past 10 years, with a number of studies demonstrating the efficacy of previous versions of the 

a large-scale randomized controlled trial

 with N = 362 participants recruited from United Kingdom (UK) clinical psychosis services (

, compared to the minimum 16 sessions recommended by the UK’s National Institute of Health and Care Excellence guidelines for schizophrenia treatment.

Remarkably, despite being half the minimum recommended length, SlowMo had a moderate effect on the measures of delusion severity commonly used in trials (Scales for Assessment of Positive Symptoms, SAPS

 and Psychotic Symptom Rating Scales, PSYRATS

)—for which meta-analyses have found only small effects.

 These positive effects sustained or grew over 6 months, with benefits cascading into other areas, including self-concept, wellbeing, and quality of life. Less consistent improvements were found for referential delusions, meaning that the Green Paranoid Thoughts Scale (GPTS)

 total, which is comprised of ideas of reference and persecution subscales, was not significant at 6 months. However, a psychometrically improved version of this measure, published whilst the trial was being conducted, did reach conventional levels of 

 Importantly, the SlowMo software design appeared to work as intended and was inclusive for a wide range of individuals. Whilst Black people and older patients were found to be less confident and less frequent users of mobile phones prior to doing SlowMo, these differences did not translate to their experience of the therapy, with paranoia outcomes, adherence, and patient experience comparable across groups.

 SlowMo is one of the first digital therapeutics for paranoia to overcome the digital divide associated with age and ethnicity.

The trial also had limitations. First, despite clear improvements in more severe persecutory delusions, consistent improvements were not found in milder referential delusions. One explanation is that SlowMo helped patients manage ideas of reference and their experiential components (eg, being watched by others), which prevented their elaboration into persecutory delusions (eg, being hunted by the mafia) but had less of an effect on directly modifying these underlying ideas of reference. This suggests that digital therapeutics for paranoia need to consider the broader phenomenological context fueling worries.

Accordingly, future versions of SlowMo will incorporate content on how to notice, understand, and manage the sensory-perceptual experiences (including altered salience and anomalous experiences) that are common obstacles to therapeutic change. The trial also did not control for effects of time with a therapist. TAU was chosen as the comparator condition because there is a low penetration of evidence-based psychological treatment in mental health care, thus the key question is whether SlowMo therapy confers benefits over and above standard care. Further, we had previously established the superiority of an earlier brief version of the intervention against an active control intervention, suggesting SlowMo’s positive effects are 

To illustrate SlowMo, Alex (name changed to protect their identity) has kindly agreed to us sharing their experience of therapy. Alex (a Black British Caribbean man in his late 20s) came to therapy reporting a strongly held distressing belief that he was being followed by a past acquaintance who intended to harm him and his family. In early sessions, he used the webapp to visualize these fears as personalized worry bubbles, and to build a picture of his fast thinking, including triggers and the impact on his life (

Alex could view and modify his personalized worry bubbles on the mobile app, which helped him develop an awareness of times when he thought fast. The SlowMo sessions then supported Alex to find ways to slow down for a moment and feel safer.

Alex connected with interactive stories of others discussing their own worries and tendency to jump to conclusions in everyday life. Reflecting on how these stories related to his own experiences, Alex audio-recorded messages to remind him how to slow down his worries. Using SlowMo tips, he created colorful, safer thought bubbles as he progressed through the therapy. Crucially, the synchronization of the web app with the mobile app meant that he could access this personalized helpful content (SlowMo strategies, messages and safer thoughts) when he needed them most. This helped him to consider alternative explanations when fast thoughts were triggered in daily life, for example recognizing that screams and laughter on the street could just be “people having fun” and not specifically related to him (see 

). Alex described how the principle of slowing down his thinking became “almost automatic” through early and regular use of the mobile app. By the end of therapy, Alex reported reduced fast thinking, distress, and conviction related to the fear of harm from others. He described how SlowMo therapy had helped him to “slow down…think different, act different, and feel different.”

As discussed in this article and exemplified by the SlowMo approach, therapy is likely to be most effective when it targets evidence-based processes that maintain distress (eg, fast thinking) whilst also being tailored to individual needs. Close attention to the patient experience of therapy is critical to deliver interventions that are accessible, engaging, and memorable.

A guiding principle of SlowMo is that assessment and intervention should include working with the patient in real-life environments, where fears of others are triggered (eg, public transport or crowded markets). This allows therapeutic targets to be understood in the broader context of the individual’s life, including relevant social factors such as experiences of poverty and discrimination.

It is crucial to promote and consolidate helpful learning and embed this into daily life, and digital tools represent a powerful method of achieving this. While SlowMo utilizes carefully designed digital tools, aspects reported by people as helpful (eg, recording and accessing helpful messages) may be replicated in simplified form using functions typically available on mobile devices.

Having found evidence for SlowMo’s efficacy and user friendliness, we are developing a new version for rollout in mental health services, which will build on its strengths while also addressing some of its limitations. We are encouraged by our findings to date, but the reality is that most digital therapeutics fail to be implemented outside of clinical contexts, due to organizational, provider, and consumer barriers.

 Further development is therefore required to deliver the benefits of SlowMo in routine care. Some challenges are beyond the direct control of developers and require governmental and provider intervention, such as access to hardware and data, and opportunities to acquire digital literacy skills. In line with these concerns, the next version of SlowMo will provide training on how to use the software, focus on a broader range of worries, and include additional tools to support therapists in providing evidence-based strategies to their patients. Implementation research is now required to establish whether efficacious digital therapeutics for paranoia can deliver on their promise of being a solution for transforming psychosis care.

is a professor of clinical psychology at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She is one of the pioneers of cognitive-behavioural therapy for psychosis and has led evaluations of innovative digital therapeutics for psychosis, including AVATAR and SlowMo therapy. 

 is a clinical psychologist lecturer at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. She led on the development of SlowMo therapy and investigates the user experience of digital therapeutics. 

 is a research clinical psychologist at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. He is the therapy lead for the AVATAR and SlowMo therapy teams.

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 Digitally supported CBT to reduce paranoia and improve reasoning for people with schizophrenia-spectrum psychosis: the SlowMo RCT. 

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, Paranoid Thoughts Scale (R-GPTS): psychometric properties, severity ranges, and clinical cut-offs. 

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A new digital therapeutic helps patients with psychosis to slow down and manage their fears.

Psychiatry’s Problem With Paranoia—Is Digital Part of the Solution? 

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Non-antipsychotic catecholaminergic drugs for antipsychotic-induced tardive dyskinesia.

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Vitamin E for antipsychotic-induced tardive dyskinesia.

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What do we know about TD? What is on the horizon? Take the quiz to learn more.

Tardive Dyskinesia: 8-Question Quiz on What We Know

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

 is the Dr Frances S. Arkin professor and chairman of the department of psychiatry, professor of psychiatry and medicine at Tufts University School of Medicine, and psychiatrist-in-chief at Tufts Medical Center. Dr Summergrad served as the 141st president of the American Psychiatric Association from 2014 to 2015. He is also a past president of the American Association of Chairs of Departments of Psychiatry and is Secretary for Finances of the World Psychiatric Association and a member of the WPA executive committee. Dr Summergrad’s research focuses on mood disorders, medical-psychiatric comorbidity, and health system design. He received the Distinguished Faculty Award from Tufts University School of Medicine in 2015 and the Leadership award of the American Association of Chairs of Departments of Psychiatry in 2018. He was elected to the Honorary Fellowship of the Royal College of Psychiatrists, their highest honor, in 2020. He is the lead editor of the 

 (2020, American Psychiatric Association Publishing).

In many ways, Dr Summergrad exemplifies the best of psychiatric leadership. He has a charismatic and warm persona, an in-depth knowledge of psychiatry’s history, an appreciation of its pluralistic roots in medicine as well as psychoanalysis, and a preference for taking the long view of psychiatry’s development as a field. I was pleased to be able to speak to Dr Summergrad about his intellectual development, his views on psychiatry’s identity, and the challenges facing the medical model and psychiatric classification.

 Perhaps we can begin with the trajectory of your intellectual and philosophical understanding of psychiatry, particularly how you have navigated the psychoanalytic as well as neuroscientific aspects of psychiatry over the course of your career?

 I have been thinking a lot about this, and I do not know that I can separate any of this from certain cardinal experiences of my life. So, I think we will have to take a little detour into my life story and how I entered medicine and psychiatry.

I am a child of the 60s in the sense that I was in college during the 60s. That was an extremely disruptive time in American history for a variety of reasons, and it became a disruptive time in my own life as well. I had been interested in psychiatry well before that, probably since I was 14 or 15 years old. For some reason, I was just pulled towards psychiatry. Maybe it was because I read 

in high school, or because I had also worked at a camp run by a Jewish social welfare organization. There was a cohort of kids at the camp who had emotional and social difficulties. As part of that experience, we learned a bit about how to work with kids who had emotional difficulties, and that also reinforced my interest in psychiatry.

I started college in 1967. Looking back on it, I doubt that I was clinically depressed, but it was definitely an emotionally turbulent period of my life. I was significantly thrown off both by where I was living as well as by my living circumstances. I hated Buffalo and its winters. Going outside in the winter there seemed like crossing Siberia to a New York City native. I was not really prepared for it. And I was a freshmen male living in gender segregated rental housing off campus. During that year, I took a course on the 

, which as you know is one of the foundational texts of Buddhism. I was very much drawn to that course, as well as to another course on Chinese history, but otherwise I felt very disconnected from school. Like probably a lot of other college students at that time, I started smoking cannabis. In the spring of that year, I took LSD—I am certainly not advocating for the casual use of psychedelics or cannabis here—and I had a profoundly religious experience. It was as if I had been dropped into Nirvana, perfection, holiness, oneness. It was a deeply mystical experience, and it also changed my thinking about the 

. It made me think a lot about neurobiology and consciousness, because if a tiny dose of a drug like this could change one’s perception so profoundly, what did that mean regarding how we understand the mind-brain relationship, and relevant to psychiatry, the etiology of mental illness?

Partly as a result of that, I then went on to study Zen Buddhism and considered training as a Buddhist monk. I ended up spending a couple of years doing very intensive Zen Buddhist meditation at a training center in Rochester, New York. There was no drug use of any kind and a fairly ascetic lifestyle. Towards the end of that period, I spent a year in a self-imposed isolation, in a liminal state, because I really felt that I needed to cut out the external messages of the dominant culture to discover what I really wanted to be and do. At the end of this period, I had a couple of important dreams and one of the dreams was extraordinarily powerful, a great dream in the Jungian sense, which basically resolved my dilemma. I woke up and my crisis was over. I knew exactly what I wanted to do and how to integrate the various strands of my life. I knew I wanted to go to medical school and to likely become a psychiatrist.

In medical school it turned out that I really liked medicine, and I ended up training in internal medicine for 3 years before I trained in psychiatry. The medical training left a deep influence. I was impacted by being in a medical setting where neuropsychiatric conditions were among the most common admitting diagnoses. When I was an intern, probably a third of the admissions to the medical service were due to altered mental status. I realized that in practically every rotation, the only thing I really cared about was the neuropsychiatric consequences of the medical conditions I was studying. So, I really could no longer resist the siren song of psychiatry, but I was impacted by my medical training, such that for me, the boundary between medicine and psychiatry has always been very porous.

 What sort of notion of psychiatry did you have at that time, and how was it influenced by your earlier mystical and meditative experiences?

: My sense of psychiatry was in part tied to depth psychology and psychoanalysis. Given my Jewish background, and given Freud’s own cultural Jewish identification, there was a pull towards psychoanalysis from a cultural standpoint, but there was also a pull towards it as being somehow central to psychiatry. 

 provided me with a way to merge my experiences with dreams, meditation, and psychedelics with my interests in medicine and science.

I went on to undertake psychoanalytic training at the Boston Psychoanalytic Society and Institute. Despite my psychoanalytic training, I thought psychiatry had to be profoundly anchored in medicine, and by medicine I am broadly including here internal medicine, neurology, as well as the neurosciences. For my residency I went to the most medically oriented psychiatric program in the United States, which was Massachusetts General Hospital. Tom Hackett, MD, was the chief there when I was a trainee. His view was that if psychiatry was not anchored in medicine, it was kind of homeless, from a clinical as well as operational standpoint, and I agree with that. I think it is unfortunate that a lot of the time as psychiatrists we end up giving away our connection to the rest of medicine and neurology. The other side of it is the risk that we may justify our existence as physicians by overvaluing what seemed to me to be a narrower 

. I think if we were more secure in our relationship with medicine, we might not see quite this tension within the profession.

 How did you reconcile psychoanalysis and neuroscience in your mind?

 Early in his career, prior to the development of psychoanalysis, Freud wrote a book called 

, which was officially published in 1950, well after his death. I felt that my interests in neurobiology and psychology came together in 

 which mirrors, especially in its critical seventh, metapsychological chapter, 

 Freud was really struggling with how to place his interest in depth psychology in the context of the burgeoning neurobiology of the late 19th century. The late 19th century was a fertile period: the neuron doctrine was being established. 

 produced his first drawings of neurons around that time. Freud attempts in 

 to use what he understood as the accepted neurobiological model and tried talk about how this whole apparatus works to generate mental states. I thought that he engaged with that issue in that book in a much more profound way than psychoanalysis has subsequently. Freud was severely limited by the neuroscience of his times, but he was convinced that a scientific explanation of psychological phenomena in terms of neurobiological phenomena was possible. He basically thought of psychologic states in parallel to the physiology of the brain that, while separate, they were “dependent concomitants,”

 and I think this central idea provides a potential means of reconciliation.

 In the mid-20th century, the psychiatrist 

 was commissioned by the World Health Organization to review existing psychiatric classifications. He noted in 

Recently, the attitude of many psychiatrists towards the conventional type of classification has become one of ambivalence, if not of cynicism… classifications based on the Kraepelinian system have continued to be used in some form or other all over the world. Many psychiatrists have done so under protest and expressing their disbelief in the working hypotheses underlying that system.

This description strikes me as quite applicable to our own times. The controversy surrounding the development of DSM-5 and the on-going search for alternative classification frameworks reveals just how deep the dissatisfaction is. What are your thoughts on why attitudes towards classification continue to be ambivalent in the psychiatric community, and what do you see as the path forward?

 The dynamic as described by Stengel does seem to exist. I think that we tend to get into a lot of unnecessary battles around classification, regarding how we classify and what we classify, as if these were not constructs imposed on real conditions. It is not that psychiatric disorders are not real. They are terribly real. All you need to do is take care of someone who is experiencing a severe episode of mania or catatonia, to know that they are profoundly and powerfully real. I tend to see psychiatric classification as more of a tentative and open-ended iterative process, subject to revision by evolving data and models of disorders. . This is a difficult task, as you know, we are dealing with things at multiple levels of observation. Take Research Domain Criteria (RDoC), for example. Even if you are going to use RDoC to do a research study, you still need to select and study a group of patients using some form of clinical categorization, whether it is something broad as mood disorders, or specific symptoms such as anhedonia, etc. There was recognition in the 1960s and 1970s, by the group of psychiatrists at Washington University in St. Louis as well as Robert Spitzer, MD, and colleagues that there needed to be some operational criteria to ensure reliability of observations. This recognition emerged in the context of many studies which had showed the poor reliability of various diagnoses at the time, such as the differences between the diagnoses of bipolar disorder vs schizophrenia in 

I think the development of our current nosologies in the 1970s was an understandable reaction against a lack of scientific rigor, at least around reliability. It starts becoming a problem when the operational constructs become reified as real, as valid. This will be relevant to our discussion regarding the medical model as well, because mental disorders are profoundly personal and intimate, and they affect one’s deepest sense of who one is. A psychiatric diagnosis can be heard as somebody saying that it is as if your intrinsic being is somehow medically defective or genetically defective; it is not just that your body is diseased, but that 

 are diseased, with the implication that you may be unchangeable.

Tensions emerge from well-reasoned and well-intentioned attempts to get closer to the truth about the causes, etiologies, and the treatments of disorders. I think that to a great extent, our diagnostic systems, whether it is DSM or ICD, have been helpful with regards to clinical practice and research, in allowing us to do systematized studies, because after all, we want to know whether the interventions are actually going to help somebody or not. We want to know with some degree of medical certainty whether we can recommend electroconvulsive therapy for the treatment of catatonia or for certain kinds of major depression, or whether we can or cannot recommend antidepressants for individuals who have bipolar depression. We cannot do that, we cannot really tell whether we are going to help patients or hurt them, unless we utilize reliable categories. These practical considerations are one of our primary obligations.

Again, I think that we struggle with this in part because the problem is so difficult, philosophically and intellectually, because it relates to the very things that we experience as the most intimate parts of ourselves, and also because we do not fully understand how the brain and the mind interrelate and interact. In fact, setting these difficulties aside, even if you look at general medicine, things are bit more clear-cut, but a large number of patients who present to general medical clinics have medically unexplained symptoms or they remain undiagnosed in terms of etiology. So, things are not always straightforward in rest of medicine either.

 The impression I get from your description of classification is that we need to take it a little less seriously. That we need enough that we can do our practical and scientific work with some structure and reliability, but it becomes problematic when we start to ascribe metaphysical importance to these operational constructs.

 Yes, that is right. When we reify these categories, we almost make them unchangeable objects. In order to begin to approximate validity, we need to be able to formulate hypotheses and then test them, and the only way we can do so is if we begin with some reliable way of describing the phenomena. Our diagnostic categories and our rating scales have a lot of limitations. We are relying on self-report, communications, physician observations. So, we always have to approach them with some degree of humility.

 Going back to your personal experience, when you were 18 years old and in that phase of emotional and existential turmoil, someone could very well have suggested that you were suffering from clinical depression and that you needed to see a psychiatrist. How do you think you would have reacted to that?

: In fact, I did get that message. That I was clinically depressed, and that I just needed to see a psychiatrist and be on the right antidepressant, and all of this would go away. I strongly rejected that message. The very last thing I was going to do at that time was to go see a psychiatrist. So, I understand where some of this resistance against the so-called medical model comes from.

If you had taken me at age 18 or 19, and had tried to look at my experiences at that time through the lens of a diagnostic or medical model, I would have agreed with the critics that the medical model was not the best frame for this. But if I had had to drop out of school because of intrusive obsessional thoughts or compulsions that may be quite different, and the medical model is in my view an appropriate frame of inquiry. Or perhaps I just do not have an accurate view of my 18-year-old self. I think that one critique of the medical model, as it is understood by many, is driven by a concern that we are judging individuals, pushing them away, not listening to their experience, and distancing ourselves from them by labeling them. We always have an obligation to listen and to be prepared to revise our thinking,

 The medical model in psychiatry is facing considerable opposition from many prominent critics. How to best understand the medical model is a complex issue, something we briefly touched on in your interview for 

 and in this series I have talked about the medical model in detail with 

 A question I would like to ask you is about the limits of the medical model. The concern around medicalization reflects a growing anxiety that more and more of our lives are being viewed through the medical gaze. It is perhaps to be expected that as medical practitioners we tend to focus on the ways in which the medical model can improve lives, but at what point does medicine say to itself, “Maybe we are not the best professionals to address this. Maybe this is a situation where we should let our colleagues in psychology and social work take the lead. Maybe this is a situation where the medical understanding of a condition should not dominate over or should not exclude a more psychological, social, or existential understanding of the phenomenon”? How can medicine be more reflective over its own limits and boundaries?

 Everything depends on what we mean by the medical model. To me, in its most basic form, the medical model is a hypothesis-generating method, the roots of which can be traced back to 

 among others. The basic idea is that there are signs and symptoms that assort together more likely than would be expected by chance, and we recognize them as syndromes. If we properly define what the syndrome is, we can begin to then investigate what causes it and how to treat it. This is an incredibly fertile thread that runs through all of medicine. This is the sort of thinking that serves as the foundation for 

’s pathological studies. It is a syndromic model, which leads to a hypothesis, which leads to investigation, and then the results of these investigations may force us to redefine our syndromes or redefine our hypothesis, so it is an iterative process as well. In this iterative process, diagnoses can be lumped together, or they may be split further, or rearranged in other unique ways. The syndromes are intended to have parsimonious explanations, to achieve

, “the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible.”

When individuals use the term medical model in psychiatry, I think what they mean is that psychiatrists are ascribing a medical cause to an individual’s experience or feelings. So when we, as psychiatrists, ascribe a medical cause to the feelings and experiences, we are referring to some ineluctable and unchangeable element about the individual, with the implication that their very essence is dysfunctional or pathological. That is, in my view, a mistaken understanding.

Do I believe that some of the experiences in the realm of psychic suffering are better understood as existential rather than medical? Absolutely, I do. I do not believe that every form of mental suffering or emotional suffering is a mental disorder, but do I believe that there are mental disorders which are best understood through the syndromic lens. DSM is a variant of this syndromic model, and it is a very useful tool to categorize mental disorders, a tool that also provides us with ways to validate our constructs, with validators such as course of illness, family history, genetics, biology, and a variety of other things that have been well-described by 

, among others. These validators help us put some guardrails around what we are postulating through the syndromic lens.

 I think the thing that concerns or worries many critics is that when something is viewed through that syndromic lens it tends to crowd out other ways of understanding it.

 It is an important worry, but it is not a necessary consequence of the syndromic view. Do all human experiences fall within the realm of medicine or psychiatry? I do not think they do, or that they should. I think that would be a mistake. In other words, there is definitely a risk that our diagnostic concepts can be over-extended and that everyday life can be medicalized. That is something we have to guard against.

I do think we have both an obligation to say, 

this is our best evidence of what is effective for this kind of entity

, and an obligation to recognize that not all emotional or mental states are best understood through this syndromic medical model. Neither the profession nor the general public is well-served by medicalizing ordinary human experience. It also does not mean that psychotherapy cannot be beneficial for developmental or existential concerns. It can be. Freud viewed the goal of psychoanalysis as converting neurotic “misery” into “common unhappiness.”

 The challenge we face is not to convert human unhappiness, what my Buddhist teachers would call, in the Pali Canon, 

 I really liked something you said in your presidential address to the APA

My bias is to look at the long, far view, if for no other reason than change is hard, complex, and always takes longer than we expect. We tend to look for instant transformation, analysis, and understanding, which is not always forthcoming, reliable, or desirable. This is especially true at times of great upheaval and uncertainty, which we are certainly experiencing in the sciences related to psychiatry, and more broadly in technology and culture.

It seems to me that the discourse in psychiatry has tended to fluctuate between extremes of enthusiasm and disillusionment, with this cycle repeating every 30 to 50 years. Do you think adopting the long view can help us avoid getting trapped in this cycle?

: Part of the reason why I think the long view is useful is that it allows you to see the changes that have actually happened. If we are too close to the events in question, it is hard to know whether meaningful or long-lasting change has taken place or not. I think if you take the long-view, the comfort that exists in contemporary culture with regards to talking about mental illness, the protections that exist within law, the reimbursement of care from insurance companies for psychiatric conditions (imperfect as it is), and the increased awareness regarding human rights in psychiatric care, all of those things to me represent advances in the course of history, but you cannot see them if you are too close to them. There is this story of Henry Kissinger, PhD, meeting with Zhou Enlai, the great Chinese prime minister, during the opening to China in the early 1970s. The story goes that they were making small talk before the visit and Kissinger asked Zhou, “What do you think of the impact of the French Revolution?” Zhou paused, and replied, “Too soon to tell.” I think that captures well my own sentiments.

 Speaking of the long view, in a 2013 editorial for 

, on the 100th anniversary of Karl Jaspers, MD’s 

; Mario Maj, MD, PhD, commented on the analogies between Jaspers’ historical context and our own. 

The most striking analogy is that nowadays, exactly like one century ago, the enthusiasm brought about by a period of exceptional progress of research in neurosciences is being followed by some disillusionment, due to the limited relevance of that progress to the elucidation of the pathophysiology of mental disorders.

 I do think that eventually we will learn a lot more about the organization and the functioning of the brain: how it works, not just at the genetic or the cellular level but also at the circuitry level, such that we would begin to link the activity of the brain circuits with certain states of mind. We can already do that to some degree already, but we will be able to do it better, with more precision and explanatory power.

That is not to say that everything can be or should be explained by neurobiology. You know, again, one of the implications of my psychedelic experience for me has been that it is hard to think about these issues with our current limited understanding of the mind-body problem.

A difference between where we are now and where we were a hundred years ago is that the late 19th century, early 20th century was kind of the end of that neuroscience period. 

In this conversation, a former APA president discusses mystical and meditative experiences, reconciling psychoanalysis and neuroscience, and tensions surrounding the medical model. 

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