Psychopharmacology, while an essential tool, is only one of those tools.
I feel like I was one of the lucky psychiatric trainees. I was in the 1976 graduating class of psychiatric residents from Harvard Medical’s Massachusetts Mental Health Center. I can remember it as if it were yesterday: Elvin Semrad, MD, consulting on a complicated case of a man who had spent a great deal of his life in prison. Of all the multiple tangents and rabbit holes of this man’s complicated presentation that Dr Semrad could have followed, he asked a rather surprising question: “Have you ever been in love?” In contrast to a punch line, a surprising ending to a joke; this was an entrance line and master clinician’s surprise start to a conversation about the heart. The helped to draw out this man’s basic humanity, the dramatic stories that highlighted his sociopathy stood in sharp contrast. In the end, the multiples layers of diagnosis yielded like leaves falling off the tree, and what we saw in front of us was simply another human being suffused in hopes, dreams, and saddled with suitcases full of disappointments. We were being taught with great clarity and skill that aspect of our work which is to draw out and relate to the basic humanity of others.
One floor below this conference room: Joe Schildkraut, MD, was busy in his lab doing the research the helped make Elavil and Tofranil the first successful generation of antidepressants, helping to illuminate the role of neurotransmitters: norepinephrine, dopamine, and serotonin.
Now, nearly 50 years later, it is time to take a sober look at how our field has evolved or perhaps devolved during this time-period.
A Shift Towards Neurotransmitter Specialty
My take on this is that the focus in our field has greatly shifted and we have been increasingly relegated to the role of neurotransmitter specialists. Now we can add glutamate and neurotrophic growth factor to the mix. The benefit of this shift is that we have become more proficient at picking individual psychiatric medications, or cocktail combinations based upon neurotransmitter assessment and can leave the more time-consuming personal engagement of our clients to our talented nonmedical colleagues. In many clinics, this division of labor is an absolute necessity.
The downside of this shift, which is the main thesis of this article, is that we have over-shifted,
placing way too much emphasis on neurotransmitters with a kind of tunnel vision effect that is pushing us to often truly miss the forest for the trees. My argument is the true strength of our field has been our ability to rise above the presenting noise, as Dr Semrad did and see the big picture. I will explicate a route back to our heritage.
Recently, I attended a psychopharmacology dinner and asked one of the presenters how his career changed over the years. He said he used to spend an hour with each patient and now he spends 10 minutes. Also embedded in this transition were the financial incentives for doing so. This story saddened me. Back in my training days, we used to refer to such colleagues as psychopharmacology specialists, but it is no longer a selective few; it is the whole lot of us. My sense is we are leaving behind our true big picture heritage and have become pressed into a ‘medical model-urgent care’ type of diagnosis, quick look at the x-rays, treat, and move on to the next. Our patients clearly want to be on the right medications, but they also want to feel known, cared for, and understood. Diseases may fit into a medical model; patients do not.
Another example: a colleague of mine was trying very hard to help his patient who had been stuck in grief since the loss of her mother over a year ago, treating with different carefully selected antidepressants. None of his medication changes worked and he was at a loss about what to try next. What I suggested to my colleague was to do some form of basic grief counseling. Have his patient go to the grave site. Discuss what her mother might be advising her to do now. But how does a neurotransmitter specialist shift back to being a grief counselor when there are malfunctioning synapses sitting right in front of him, and the pressure is on to find the right medication?
Black Bag of Options
I go back far enough to remember the days of the home visiting general practitioner with the black bag. When I was sick with tonsillitis as a kid, my general practitioner would come to the house, reach into his magician-like black bag of tricks and pull from the bag what he needed, a stethoscope, a thermometer, or—God forbid—a needle. My view of my own career development is this: I have continuously added to my black bag of options to offer patients. That we can readily include medication options is a blessing. However, as a profession we have become too exclusively tethered to them and that is a problem. These days psychiatrist means being a prescriber. We need to be prescribers for sure, but not confined or defined by that role. We need to re-empower our big picture identities in which selecting medication is just one of the many services we offer.
In my career path, I became one of the founding members of the American Family Therapy Association, which fundamentally recognizes the power of groups and relationships to harm and heal. Later, I also became an addiction specialist, then an ADD specialist. In the last 20 years, I have added 2 additional specialties: mindfulness trainer and brain educator.
In my work with addiction, I was struck by the self-harm aspect of the condition. This led to my wondering in more detail why humans are the only species that self-harms. While I could comprehend a part of the brain being addicted to nicotine, alcohol, or an opiate, I could not comprehend the concept of being addicted to self-harm. This then led me to research the evolution of the part of the brain called the amygdala, the fight or flight area of the brain that exists in all mammals. This in turn lead me to examine the way the human amygdala (seat of aggression) differs from the amygdala of other mammals. Noteworthy, is that it directs aggression both inwardly and outwardly. Inner directed aggression is at the core of a huge percentage of our human psychic suffering. The study of the amygdala then led me to the pre-frontal cortex, the seat of inner self-awareness, and the realization that the pre-frontal cortex could be educated and trained to be aware of the inner-directed aggression. This then led me to the development of a brain education-based mindfulness training program that is outlined in my book, Me Myself & My Amygdala: A Mindfulness Guide to Sobriety & Recovery. Inviting our patients to learn and have conversations about the human brain is a creative, nonthreatening approach to concretely help our patients in the development of insight. While looking into the brain is a rather literal form of insight, it is a starting point and a glimpse into our shared humanity.
Another approach to our shared humanity was introduced to us by another of my esteemed Massachusetts Mental Health Center mentors: Leston Havens, MD, who taught us to the interviewing approach of trying to find a shared reality with your patients. The essence of this approach was to have conversation with your patient as if you were sitting side by side with your patient (not across from), watching the same movie and then describing what you saw together. In the mindfulness group education programs I run, I bring a brain model into the groups as a focal point and springboard to conversations about our shared humanity.
Perhaps psychiatrists becoming brain educators may be an additional path forward. As a brain educator, you would need to be knowledgeable about neurotransmitters and the medications that impact them, but you would also be compelled to see the big picture of how our unique human brain functions. It also raises a new perspective on the social dimension in human relationships. How does one who possesses an amygdala interact successfully with another person who also has an amygdala? We can discuss both the positive and negative aspects of this rather remarkable organ, both its advantages and challenges. What a great place to begin a discussion about our shared humanity!
One core teaching in mindfulness training is when you are aware of a thought, feeling, mental state to try to determine what part of the brain it is coming from; distinguish if it is generated by the amygdala or the pre-frontal cortex. It seems that the real estate adage: location, location, location also applies to our cortical real estate also! In mindfulness we learn that so many of our problems result from an under-utilization and underdevelopment of our pre-frontal cortex. With proper training of the pre-frontal cortex, we can learn to more effectively manage and channel what other parts of our brains serve up.
I find that about a third of the patients I see for evaluations have a negative view of therapy.How many times have you heard a patient exclaim, “I do not want to talk about the past!” But when I offer these same folks an education group or class to learn about the brain, they light up and say sure that sounds great. For folks with posttraumatic stress disorder, learning about the hippocampus, which anatomically sits right next to the amygdala, gives them a visual tool to better think about how to manage the trauma in the lives, as they can see and identify where in the brain those memories are stored. This particular brain educational approach will not serve every patient, but it is sure helpful to have in the black bag.
The case I am making here is for psychiatrists to more fully recognize the depth and breadth of their medical training and unique perspectives of their roles so that they can continue to look into the microscope, while also being able to step back and intelligently see the macroscope. In this context, I would like to mention another mentor Leon Shapiro, MD, who was a psychiatrist and dean of Tufts Medical School when I attended. In this role, Dr Shapiro was able to shape the tone of our education. I am certain the way he used his power helped me become a family therapist.
In the future, it is my hope that psychiatrists will expand their roles and not be simply typecast as prescribers. One area of particular interest to me is for psychiatrists to become more integrated into schools and teach brain education in the classrooms. So many adults who have attended my mindfulness brain education groups immediately share what they have learned with their children and repeatedly state that they wish they had learned this when they were younger.
Coming full circle here, I am so grateful that I learned from the likes of Semrad, Havens, and the other great teachers at Massachusetts Mental Health Center, as well as Shapiro at Tufts and the different ways that they promoted a big picture approach to psychiatry. For me, this means an ongoing effort to be a therapist as well as a prescriber, adding additional skill sets like couples and family therapy, adding brain education mindfulness training classes, and staying well versed in psychopharmacology. This is how I have honored this legacy. My view is that we need every tool we can learn how to use to manage effectively the many challenging patients and situations we face. Psychopharmacology, while an essential tool, is just one of those tools.
Hopefully seeing the big picture will mean a return to seeing patients in person, where our encounters are generally most meaningful and impactful with or without prescribed medications. My sense is that it is imperative that moving forward our field finds ways to re-integrate the wisdom, artistry, and mastery of our mentors who knew, taught, and implored us to find creative ways to both look at and beyond our neurotransmitters.
Dr Ackerman is a psychiatry specialist in Warwick, RI and has over 49 years of experience in the medical field.