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How can you use the 4 perspectives and 4 pathways to flourishing for practical and personalized patient care?
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.1,2
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.3,4
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.5 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.6
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: The Perspectives of Psychiatry.7 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:
1. Disease: something a person has
2. Dimensional: who the person is
3. Behavior: what the person is doing
4. Life story: what the person has encountered
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 has—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 is—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 doing—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 encountered—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.8,9 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 Perspectives of Psychiatry 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.
Dr Chisolm 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.
1. Lamb SD. Pathologist of the Mind: Adolf Meyer and the Origins of American Psychiatry. First ed. The Johns Hopkins University Press; 2014.
2. DePaulo JR, Jr. One hundred years of psychiatry at Johns Hopkins: a story of Meyer to McHugh. J Nerv Ment Dis. 2017;205(4):260-265.
3. Jaspers K. General Psychopathology. University of Chicago Press; 1968.
4. Ghaemi SN. Existence and pluralism: the rediscovery of Karl Jaspers. Psychopathology. 2007;40(2):75-82.
5. McHugh PR. Striving for coherence: psychiatry’s efforts over classification. JAMA. 2005;293(20):2526.
6. McHugh PR, Slavney PR. Mental illness—comprehensive evaluation or checklist? N Engl J Med. 2012;366(20):1853-1855.
7. McHugh PR, Slavney PR. The Perspectives of Psychiatry. Second ed. The Johns Hopkins University Press; 1998.
8. VanderWeele TJ. On the promotion of human flourishing. Proc Natl Acad Sci U S A. 2017;114(31):8148-8156.
9. VanderWeele TJ, McNeely E, Koh HK. Reimagining health-flourishing. JAMA. 2019;321(17):1667-1668.