Dr. Mark Mullen interviews Dr. Awais Aftab and Dr. Allen Frances on Psychiatry Boot Camp

In the last episode, Dr. O'Leary interviewed the creator and host of the Psychiatry Bootcamp Podcast, Dr. Mark Mullen, who is currently a psychiatry clerkship director at St. Louis University School of Medicine.  He created this podcast after discovering a dearth of resources available for medical students and junior psychiatry residents to prepare them for their transition to practice. 

He graciously allowed PsyDactic to include a couple of his episodes in this feed as a way to spread the good news about Psychiatry Boot Camp.  This is his introductory episode where he sets the tone of PBC by interviewing Dr. Awais Aftab, Clinical Professor of Psychiatry at Case Western University,  and Dr. Allen Frances, Chair of the DSM-4 Task Force and Chair Emeritus at Duke.

Check out Psychiatry Boot Camp!

https://linktr.ee/psychbootcamp

https://pubmed.ncbi.nlm.nih.gov/38724723/

https://podcasts.apple.com/us/podcast/psychiatry-boot-camp/id1671902940

https://open.spotify.com/show/4Vjlz4CO0G5D6nGo74O0jE

https://www.audible.com/podcast/Psychiatry-Boot-Camp/B0BVK4HYLW

https://x.com/markrmullen

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com.  All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else.  We reserve the right to be wrong.  Nothing in this podcast should be treated as individual medical advice.

Transcript

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SPEAKER_03 0:06

Welcome to Psychactic. I'm your host, Dr. Leary, psychiatrist and a fellow in child and adolescent psychiatry in the US National Capital Region. This is a podcast about psychiatry and neuroscience that I created as a way to help me learn more about things that I love. In the last episode, I interviewed the creator and the host of the Psychiatry Bootcamp podcast, Dr. Mark Mullen. And he's currently a psychiatry clerkship director at St. Louis Medical School. He created this podcast after discovering a dearth of resources available for medical students and junior psychiatry residents to prepare them for their transition into practice. Needless to say, Mark is a man after my own heart. He has graciously allowed me to include a couple of his episodes in this feed as a way to spread the good news about Psychiatry Boot Camp. The following is his introductory episode where he sets the tone of PVC, and it's a tone of excellence. So I'm going to stop blabbing now and get on with it.

SPEAKER_02 1:27

My number one priority with this podcast is to give you clinically relevant information that will change the way you practice and help your patients. As you might imagine, most of the curriculum in Psychiatry Bootcamp is fairly predictable, and it should be. These boot camps, often called crash courses, are increasingly popular across the nation, and the content, given its foundational nature, remains fairly consistent across these courses. That being said, episode one is the only episode in the series where we aren't going to dive directly into content that you've probably already been somewhat exposed to and are just trying to cement in your brain. In this episode, I want to carve out some space to remind us of our most sacred duty. First, do no harm. Our two experts today are leaders in the field who have helped to shape my professional identity, and when I was initially exposed to their ideas, I can vividly remember the feeling of a deep breath and thinking, Oh yes, I am right where I belong. The second half of this episode will feature Dr. Aweis Aftab and we'll discuss the validity of the DSM, what psychiatry really is, and what it is not. But our first guest today is Dr. Alan Francis. Dr. Francis was the chair of the DSM IV Task Force for the American Psychiatric Association, meaning he oversaw the creation of the manual after first having a prominent role in the creation of DSM III. He is a professor of psychiatry and chair emeritus at Duke University. He's also an author, and to give you an idea of his work, wrote a book titled Saving Normal, an insider's revolt against Big Pharma, the DSM V, and the medicalization of ordinary life. I'm also going to pitch Dr. Francis' own podcast here against my own self-interest because I found it enjoyable and nothing short of therapeutic. It's called Talking Therapy, and it's available on Spotify. Welcome to Psychiatry Bootcamp Dr. Francis. And like all of our guests, I'll ask you to introduce yourself to our audience.

SPEAKER_00 3:16

My name's Alan Francis. I'm a psychiatrist. I've been around a long time, seen a lot of things. I was chair of psychiatry at Duke and also chair of the DSM4 Task Force. And I'm particularly interested in education and trying to get psychiatrists off on the right foot.

SPEAKER_02 3:35

Okay, so first question for you, Dr. Francis. Reportedly, and admittedly this comes from your amazing podcast, Talking Therapy with your friend Marvin Goldfried. Um, reportedly, when you were kind of touring the DSM 4, you remarked before a presentation that you wrote an introduction to the DSM, but you were sure no one was going to read it. So maybe that is so, but that's also why we have podcasts because people don't like to read too much. So what was this introduction and why was it so important?

SPEAKER_00 4:03

Well, the the the uh biggest mistake in using the DSM is to imagine that each of the disorders is an independent disease, and that when you have more than one disorder, that means you have more than one disease and you need more than one treatment. The DSM categories are really just construct. They're very, very useful, but they shouldn't be worshipped and they should be understood, they shouldn't be misused. And taken out of context, we've had the experience of vast overdiagnosis, a vast overuse of medication, mindless polypharmacy. And so my efforts with DSM4, which I have to admit were not very successful, were to trim the sails of the diagnostic system, to be very conservative, to get people to be very careful before making a diagnosis, that a good diagnosis is a wonderful day in the patient's life. An accurate diagnosis can be the best day in the patient's life, that previously confusing, disturbing, misunderstood symptoms take shape. We understand this problem, we have a lot of experience with it, and we have treatments for it. And inaccurate diagnosis carries all the stigma, the risks of overtreatment without any benefit. And so the DSM4 introduction was really a cautionary statement. Use this manual carefully. Be conservative, don't diagnose too easily, too quickly. Um we didn't write this, but we should have. Diagnoses should all be written in pencil. They're hypotheses. You can't jump to a diagnosis in 15 minutes and have any confidence in it, especially in kids or in the elderly. So the introduction of DSM 4 was a cautionary statement, should have been stronger, probably, uh, about its misuse clinically, misuse in forensic settings. It wasn't read, and um that's why I do podcasts, to try to get people to be more careful in their diagnostic habits and less careless in prescribing medication.

SPEAKER_02 6:11

Well, that just sounds like your book, Essentials of Psychiatric Diagnosis, is what that sounds like. Yep. Okay, so to put a fine point on it, what are your most pressing concerns in terms of psychiatric harm?

SPEAKER_00 6:22

Well, I've worked with experts, I I guess several thousand experts over the years, and no expert ever said to me, you know, my diagnosis is being overdiagnosed, that we should trim the sails of my diagnosis, that we should make the criteria stricter. Every expert always loves their pet diagnosis, argues for it, wants to expand the criteria, worries about the mispatient, never worries about the mislabeled patient. And what this has resulted in is a diagnostic system that's way bloated. It's way too easy to make the diagnoses in the system, and some of the diagnoses that are in the system perhaps shouldn't even be there. And so we have a system now that's over-diagnosing, especially the worried well. And meanwhile, we have millions of people with severe psychiatric illness who aren't getting the treatment they need. We have 600,000 people with severe psychiatric illness who are either in prison or homeless on the streets, that we're overdiagnosing the mildly ill and the worried well, and we're terribly neglecting, shamefully, horribly, disgustingly neglecting the people who most need our help. So the system is too expansive at the mild end and not nearly enough focus at the severe end.

SPEAKER_02 7:45

You've stated in the past something to the effect of therapists are born and not trained. And I think at first glance this phrase is enough to at least raise an eyebrow. What did you mean by this?

SPEAKER_00 7:57

I didn't say it exactly that way. What I said great therapists are born, not made. That's a very important distinction. Great therapists are born, not made. That good therapists can be made better with training or worse, and that uh bad therapists are usually untrainable. And the what I meant by that is there's some people who are in therapy who shouldn't be there, who just don't have the interpersonal skills, and it's not something, well, I'll learn it on the hoof. That interpersonal skills you learn from birth, you have a lot of the capacities and born and you're nurtured in an environment that enhances them. But that's a very small percentage of psychiatrists or psychotherapists, a very tiny percentage shouldn't be in the field. The really great ones are great because they just were a combination of born that way and early nurturing. And you can make them a little bit better, maybe, but you can make them worse. I've known people who started out as great therapists in their PGY1 year, who by the time they finished uh psychoanalytic school or cognitive behavior training had become robots and were much worse than they were when they began. Training can make people worse if you don't follow the patient. If you follow your supervisor or manual to the detriment of following the patient, you're not really learning to be a better therapist, you're becoming a worse therapist. So the purpose of training, and training is very important. I spent my whole life doing training. It's not like I don't like training. But the purpose of training is to take the skills, the interpersonal skills the person was born with and developed before they ever began seeing a patient, to take those skills and enhance them, making them more sensitive to themselves, more sensitive to other people, better and interacting, just better people. Training can be very valuable in that. The techniques that informed the different psychotherapy schools are all valuable. So training shouldn't fail, I don't like training that says we're a psychodynamic program, we're a cognitive behavior program, we're straight a medicine program. That any program that sells itself in a reductionistic way is, oh, we do this one kind of treatment, is going to sell the patient short because there isn't one hammer for all the different complex problems patients present with. And every reductionistic model in psychiatry is just dead wrong that people present with great complexity of problems, and we have to be prepared to meet them where they are rather than where our training program has taught us to be.

SPEAKER_02 10:24

You used a phrase there that I hear from you a lot. Follow the patient. And I imagine that if I was your supervisee, I would have a track of your voice saying that in my head on loop every time I was doing psychotherapy with a patient. Follow the patient, follow the patient, follow the patient. But Dr. Francis, there's, to my knowledge, not been a very good manual written about following the patient. So how am I supposed to know what this means? How do I follow the patient?

SPEAKER_00 10:48

Yeah, it's tough. Um, and I never wrote a book on follow the patient because it's really so individual. It's hard to make generalizations that help you follow the patient. That most generalizations distract you from the patient. One of the things I would always say to people I supervise is don't take what we say today too seriously for your next session, because then you'll always be one week behind. That what you learn in supervision, what you learn from theory, what you learn from learning manuals, is mostly to provide a context that's available to you, not to provide a driven kind of, I'm going to go into this session with this in mind. Whenever people get supervised, the tendency is to see the thing they learned that week in every one of their patients. There's a kind of, oh, I got this idea, and now they see it in each and every one of their patients. It's really important to be there for the patient, to realize that this is the most important, maybe one of the most important experiences the patients ever can have in their life, even if it's a medication visit, even if it's a 15-minute visit, you never know when you might say something that will have tremendous impact on that person's life. I've worked all whenever whenever job I had over the whole time of my career, I always supervised in the emergency room because I thought the emergency room was the best learning experience, the most vivid time to learn psychiatry, the most acute problems, the most complicated problem, the most varied problems. Also helping you understand the community, helping you to understand your treatment system and how it interacts with patient need, puts you in touch with families. Best learning experience in psychiatry is the emergency room. One of the things I noticed was that I would see patients for 15 minutes, never see them again. And I'd have the person come up to me years later and say, you know, Doc, you probably don't remember me, but you said this to me, and it changed my life. I've also had the experience of working with people for 14 or 15 years and not changing them a bit. So it's not the quantity of work with a patient that matters, it's the quality, it's the situation they're in. The um sometimes the greater the crisis, the more the flexibility the person has to see things differently. And it's you, it's you being prepared, thinking that there is no such thing as a routine session. There never is a routine session from the patient's point of view. You may be tired, you may have seen 15 patients that day, you may want to go home, but from the patient's point of view, that could be the moment in their life that changes their life. And you also have to put your needs secondary, put your fatigue secondary, and be as alert as you can possibly be every single minute with every single patient to try to say something that will matter. People change because of corrective emotional experiences. It's never just an insight, it's never just a behavior, it's never just a change in emotions, a combination of all of these. It's finding in life or in the session, in the contact of the therapist, a way of seeing the world differently. And we have to be there to try to help them have that experience. That that requires a high degree of attention. It requires putting aside distractions, putting aside theoretical models. It requires really thinking through where is this patient in their life and what can I do to say something, to do something that will materially get them to see things and experience things differently.

SPEAKER_02 14:33

And when you frame the psychotherapeutic interaction that way, I think it helps us to consider all of our life experience prior to this and all of the relationships that we've had prior to this and the things that have changed our lives, and to feel comfortable, you know, maybe not necessarily naming it, but bringing all of those experiences into the room with the patient, not checking them at the door, not simply making a DSM diagnosis, choosing a manualized treatment, choosing a medication, but being a human who's in the room with the person, having an emotional experience. And that takes guts, you know, and you know, you talk about following the patient and how maybe no two patient interactions are the same, but you're not saying throw all the evidence in the toolboxes out the window, obviously, right? What you're saying is we need to know our toolbox. We need to know the evidence, different psychotherapeutic techniques, the medication evidence that we have. We need to know it so intimately that when we're in the room with the patient, we can fully immerse ourselves and have a dynamic experience that is emotive for both of us. And that's really hard work. I wish I had said it that well. You also talk a lot about avoiding cliches. And I think that um sometimes patients can run together in our minds, and the longer we do this, the more we see patterns of problems that people have, and hopefully at some point, patterns that work to get people out of these. So it sometimes feels easy to make that into cliches, but you talk a lot about making these magic moments, and I think that only happens if you're organic about it.

SPEAKER_00 16:01

Yeah, and and poetic. Um, finding ways of saying things that will deeply impact on a person's emotional life, that will have them see the world differently, that will have them behave differently. Um, a lot of psychiatry is science. Um we have to learn a tremendous amount about how the brain works, we have to learn uh a great deal about how the medications impact with the uh individual types of problems, which receptors are involved with which, which networks are most likely to be involved with disorders. We have to learn a lot of science. We have to learn the science of psychotherapy research, what's been understood from the studies we have available about what works with what problems. But a lot of it, when the rubber hits the road with the patient is our the science has to be, as you put it, the background of what we do, the unconscious of what we do. But the focus to the patient is not going to be, usually not going to be quoting scientific studies, although I'll I'll stop myself. With some patients, the very best thing you can do is quote the literature. So when people are feeling, especially people who like to have control, who like to feel that they understand things, when um trying to explain why this diagnosis, not another, why this treatment not another, we have to be very good in common sense terms in explaining what we're doing. If we can't explain clearly to a patient what we're doing, we probably shouldn't be doing it. Anything that requires a jarkinistic explanation is usually BS. But everything we do can be and should be reduced to simple language that makes enormous sense and that has an impact on the patient.

SPEAKER_02 17:52

I'm glad that you brought up the higher level science because I have a bone to pick with you. So I spent four years in medical school learning the most state-of-the-art science in human history to put it into my brain. And now, consuming some of your work, it sounds like you're trying to tell me that most of what I do, at least in a therapeutic sense, dates back to ancient Greece and Epicureus. So my question for you is seriously?

SPEAKER_00 18:20

Yeah, first of all, it wouldn't just be Epicureus. The Epicurean philosophers had tremendous influence on psychotherapy, but the um the Stoic philosophers had an even larger influence in cognitive behavior therapy. And both Beck and Ellis, who started, jointly started cognitive behavior therapy, both recognized, acknowledged in their early papers how much they owed to the ancient Greek Stoic philosophers. So, yeah, psychotherapy is not something that was invented in um in Vienna in the 1890s. Psychotherapy is part of the human tradition. It goes back to the shaman, uh, to the early to the priest. That we've had a and it that makes our role even more important. That if we had invented this role, it might be superficial. But we're filling a role that's a basic need of individuals that's been important in the evolutionary history of humanity, and it happens to we have the privilege at this point to be the profession, uh, or one of the professions that's filling an ancient, much needed role in in humans. And what about the science? What I say is that um, with regret, is that the um intellectual adventure of the last 40 years in trying to understand neuroscience is probably, along with trying to understand the quantum, probably amongst the most exciting adventures, understanding how we work and why we work, ever since Darwin, actually, the intellectual adventure since Darwin, Darwin greatly underestimated as the major figure in psychology. But ever since the um understanding of evolution and the almost simultaneous beginning understanding of the neuron, both of these things were happening at the same time in the 19th century, the synapse was uh understood very shortly after evolution. So the brain science and evolutionary science were moving along hand in hand. This is one of the greatest phenomena, one of the greatest intellectual adventures of mankind. However, although the NIMH has spent the equivalent of, I don't know, 50, 60 billion dollars over the last 40 years in today's dollars, all of the neuroscience that's so exciting and explaining how the brain works, as much as it's given us a tremendous foundation in understanding the brain and behavior, none of it has helped a single patient. The brain is the most complicated thing in the known universe. There are probably as many neurons as there are stars in our galaxy, about 85 billion neurons. There may be 300 trillion synapses. There's a complicated choreography and dance of the developing neuronal system that has tremendous migrations of cells in all sorts of weird ways. It's a remarkable, not that anyone ever has a problem. It's remarkable that we work as well as we do. To think there would be simple explanations for all of this neuronal complexity, for all of the vast numbers of weird permutations between brain functioning and the environment, the physical environment, the early environment, the nurturing environment, the social environment, the cultural environment. To think that there would be simple answers was naive. When we did DSM III in the 80s, there was a lot of excitement on in some quarters, not made, but there's a Lot of excitement in some quarters that with a reasonably reliable diagnostic system, we would have quick answers about what was the science under the underlying disorder. The feeling was that if we had primitive answers before then, it might be because the diagnostic system was itself primitive. That if we developed a reasonably competent diagnostic system, aha, all of the puzzles would be solved. And in the 80s, there were numerous studies on the gene for schizophrenia, the gene for bipolar disorder, the gene for panic disorder. Everyone was very excited with the idea that there was a simple genetic answer. There were all sorts of studies about the brain imaging of schizophrenia, the brain imaging of the various other psychiatric disorders. None of these studies replicated. Every simple answer study to a complex problem in understanding brain and behavior turns out to be wrong. Every reductionistic aha, this suggests that blah, blah, blah, turns out doesn't replicate. I was on the NIMH study section that did psychotherapy, finance psychotherapy studies around the same time in the 80s. And we only over the course of the years maybe funded $30 million worth of studies. But those studies, a tiny percentage of the NIMH budget, funded Marshall Lenahan's DBT, TimPeg's CBT. These have helped by now millions and millions of patients. The enormous investments at this point, 90% or more of the NIMH budget is pure biological science, doesn't even touch clinical work. And in the 10% that touches clinical work, most of it is pretty irrelevant to decision making in the office. So we've developed a brain institute that doesn't focus on patients. We have during the um 60 years that is 60 years? Yeah. It's almost 60 years I followed psychiatry since the beginning of medical school. During that period of time, we developed the most incredible tools in microbiology and genetics and in imaging. And none of them help a single patient. At the same time, we have 600,000 people in in prisons or on the street who are suffering greatly beyond what you can imagine. If you haven't revisited patients in solitary confinement in a prison, you don't know what degradation is. What I often say is that the worst place in the world to have a severe mental illness is the US. The patients are worse off now than when I began. They were in terrible state hospitals when I began, and now they're in terrible prisons and on the street. Patients smear crap cell after cell in solitary confinement in a prison, smearing crap all over the walls. Patients living in conditions that are unimaginable to people who haven't visited LA and and seen it or other cities in America where this has become so in other words, from my perspective, it's very important to learn the science, partly because it's so fascinating, but not to be overawed by it as if the science will leave a simple answer. You guys are starting your careers now. My guess is that during the course of your careers, there'll be giant leaps in understanding how the brain works, giant leaps in understanding how genes work, and very minor changes in how people are treated. Because the jump from the 20,000 genes to the 86 billion neurons to 300 trillion synapses is so complicated that there won't be a breakthrough drug. I think if there was going to be a breakthrough drug, we would have had it. The drug companies have given up research in psychiatry. They made their fortune and they left the field because they understood that it's just that complicated. So in your careers, you can't say, well, I'm going to understand all the science of the brain and I'll be ready, you know, in five years or 10 years. When that breakthrough happens, I can jump on it. Because I don't think it's going to happen. It would have happened. It's been a tremendous amount of investment in finding the breakthrough. Hasn't even happened for Alzheimer's, which is the most obvious. We don't even have a biological test for Alzheimer's. Forty-five years ago when I started working on DSM3, I began asking Alzheimer's researchers when will we have a biological test for Alzheimer's? Some of them said five years, some said 20 years. I kept asking over the years. I keep asking now. If I ask now, some will say maybe four or five years, and some will say 20 years. It's for Alzheimer's, the easiest of all psychiatric disorders to reduce to brain functioning. For schizophrenia, it will be lots longer. So I think everyone should learn the science because it's fascinating. Everyone should learn the science because it's humbling, because it's such tough questions. It's a lot tougher to understand the brain than to understand the universe, because the brain's a lot more complicated than the universe. It's had a lot of time to develop and it's weirdly complicated. Compared to the brain, the universe is pretty simple. If you understand a few things, you get the universe. To understand the brain, you have to understand trillions of permutations. So the major point for a young person starting psychiatry, I think, is to learn the science, but not be enslaved by it. And not think, well, okay, I'm a scientist of the brain. I don't have to be a healer of the person. And to develop yourselves in the context of learning how to heal. And that healing doesn't have to be formal psychotherapy sessions. For me, psychotherapy is everywhere all the time. Psychotherapy is happening all the time. And it happens in the shortest contact you have with a patient. Don't think of it as, oh, I'm just giving it writing a prescription. From the patient's point of view, that could be the moment that changes their life.

SPEAKER_02 28:11

Yeah, I think the science is sexy, right? The science is very sexy. And at that price tag, it ought to be. But it certainly makes you wonder, you know, what would have happened had we invested those taxpayer dollars in community psychiatry programs, as was promised, in stable housing programs, you know, et cetera. Um, which I guess we are investing in stable housing now in terms of the uh prison system, which you mentioned.

SPEAKER_00 28:35

Uh way too little and way too late. A really terrible, one of the most dispiriting things for me was when the Biden administration was discussing infrastructure, which is obviously tremendously important for the country as a whole and all sorts of areas. Not one single mention was ever made about improving the infrastructure for the severely mentally ill. That every conceivable form of social as well as physical infrastructure was considered. No one ever mentioned what's happening to severely mentally ill. And and I think it's an important point for career decisions that the noblest thing a psychiatrist can do now is help the sickest patients. And that people I hope will not have the idea that the best patient is the patient who doesn't really need that much help. That the most comfortable patient is the most rewarding patient. That I want an easy patient or I want a good patient. I always, wherever I work, would feel my the hairs on my neck go up. I don't get angry easily, but I would get angry at anyone, I want better patients. I've never really met, I've only met in my whole life maybe a handful of people I thought were bad patients and who shouldn't be in treatment, and they were criminals and should not be in our system. But by and large, I've never met any considerable number of bad patients. I've met some bad doctors, I've met some bad therapists. Very rarely is there a bad patient. And the therapists I've respected most, the psychiatrists I've respected most in my career, are the ones who wanted to treat the most difficult patients. Who who felt that both as a personal moral imperative, felt it as a kind of human desire to be helpful, and felt it as a as a professional challenge. That the desire to work with severely ill people is to me an indicator of someone who really I will respect the most as a uh professional. And people who gravitate toward the easy patients have they get the best results because the placebo response rate for easy patients is enormous. And just being in the room, most easy patients are going to get better. You can just be there. You don't have to do anything that makes a difference. But to feel that you've helped someone wouldn't have gotten better. The more severely ill a person is, the placebo response rate starts reducing to zero. When you help someone who you have a strong sense would not have gotten better without you, there's no greater reward in professional life, and in some ways, no greater will reward in life than having been able to do that.

SPEAKER_02 31:32

So, Dr. Francis, you have, I'm glad you brought up Marshall Lenahan and DBT and the manalized therapies and the NIMH funding committee that you sat on. Um my understanding is that many of these so-called evidence-based therapies had to create manuals in order to design proper studies, get funding from the NIMH. And in medical school, therapies that have corresponding manuals are taught as the gold standard. And in some cases, I think the only thing that many doctors know about psychotherapy, but you've also levied some concerns about manualized therapy. Could you go into some of these concerns for us?

SPEAKER_00 32:05

First of all, the the manuals have served a wonderful purpose. So you could not get funding without a manual. If the treatment is not being delivered in some reliable fashion, you can never get the standardization of medication, this pill with this chemical and this dose. But if the therapy is completely given in individualized ways by each therapist the way they like doing it, you could never generalize from the study to understand anything about what the therapy was doing. It would be more the aggregate of the individuals. So we required manuals. But um there and the manuals have had another great uh practical benefit, that across the world, in many different countries, the um provision of manualized treatment that led to research studies proving that the therapies worked as well as medication led to reimbursement for therapy. So that for most mild to moderate problems, psychotherapy does as well as medication, maybe a little slower, but it has much more enduring effects. And this led to, in in many countries, the reimbursement for psychotherapy going up, which allowed there to be more therapists and reduced some of the over-reliance on medication. The downsides are people taking the manuals too seriously. So, like the the uh manuals that were developed by the Beck Institute, by Tim Beck, who found her, and by Judy Beck, the current wonderful leader. I think she's the best therapist in the world, Judy Beck in Philadelphia. I think they themselves have said over the decades, these manuals are for research purposes. They don't train to the manual. It's important to understand the concepts, but as you said earlier, and better than I've said it, it's important to understand the concepts so they're automatic, but not robotically repeated in a manualized fashion. And the tougher the patient, the less you can depend on the manual. The more you have to be flexible and follow that patient where they're going according to their needs and their pace. So I think reading manuals, uh studying manuals, uh learning manuals, making manuals part of your unconscious or materium, very important. But worshipping manuals and rotely following manuals means you're not following the patient. You mentioned a podcast I do with Marvin Gulfreed Talking Therapy. And Marvin's been working for 40 odd years on integrating psychotherapies. The initial paper, the best paper ever written in psychotherapy, was written in 1939 by Rosensweig, and he predicted that all the different therapies of psychotherapy would have beneficial effects because there were common factors, common relationship factors across the different psychotherapies that are very powerfully involved in promoting change, that relationship factors are not radically different for the different forms of therapy. A corollary of this is that a competent therapist has to be good at that which is common across the therapies, but also has to be good at all the various different techniques. So I think a competent therapist should be very good at cognitive techniques, very good at behavioral techniques, very good at psychodynamic techniques, good at family techniques, and be able to meld these into a coherent, authentic whole within his or her personality style. And the therapists who are stuck on one model, and the popular one now is trauma-informed therapy, are hammers looking for nails.

SPEAKER_02 35:50

And, you know, we know that one of the main ways that therapy works in the long term is this corrective emotional experience, feeling seen, heard, understood. And what could be more invalidating than telling your story to someone and feeling like they are wedging your life story into a very narrow, manualized approach, and they are um twisting what you're saying and trying to repeat it back to you using jargon, you know, it's really invalidating, and it doesn't help people to feel seen, heard, and understood. It helps people to feel like they are a research subject or something. I don't think that's very healing.

SPEAKER_00 36:23

And that's how why in some cases training can make people worse because they're too self-conscious about applying techniques and not being themselves. Let me say one closing thing that I can't imagine a more satisfying profession than psychiatry. So I I feel awful about the fact that on my watch these last almost 60 years, that the severely ill patients are no better off and maybe worse off many of them than they once were. So that's an awful feeling. On the other hand, I can't imagine a more fulfilling life because of the relationships, partly with colleagues and students. It was always fun teaching, and I like being with my colleagues, but mostly with patients. And one of the segments that of the podcast that Marvin and I did was focused on how therapy makes you a better person. That I was a much better person in the rest of my life because of the help the patient had gave me in maturing me and teaching me stuff about them, about me, about life in general. So there's no better profession. And the main way to make it rich is to never be a robot doing it, to never get jaded doing it, to never feel this is a routine interview, to not let yourself just become a pill pusher, to always regard the privilege and the wonder of getting to know people in this very special way.

SPEAKER_02 37:53

And what I took from that episode and the impact that it made on me was pretty profound because I hadn't thought about it that way. But what you're talking about is allowing ourselves to be changed by this experience, by this profession that we've chosen. And if we are our best person when we're practicing psychotherapy, it helped me to step back and say, what do I like about myself when I'm being a therapist? And how can I incorporate those qualities into the rest of my life? And I think that's what makes a vocation really fulfilling.

SPEAKER_00 38:21

That's pretty amazing. You say the things I say, but you say them better than I say them.

SPEAKER_02 38:25

I guess I'm learning well. Dr. Francis, thank you so, so much for coming on. Our next guest is Dr. Awise Atab here to talk to us about some of the more philosophical aspects of psychiatry. Dr. Atab, welcome to Psychiatry Bootcamp, and I'll ask you to introduce yourself to our audience.

SPEAKER_01 39:13

Thank you, Mark. I think this is a wonderful initiative, so I'm really glad to be a part of this. I'm a psychiatrist in the Cleveland area. I'm clinical assistant professor of psychiatry at Case Trust and Reserve University, and I'm pretty actively involved in educational initiatives related to philosophy of psychiatry, conceptual psychiatry, and critical issues in psychiatry. So I'm pleased to be talking about these issues in this episode as well. And I'm very active online, I'm active on Twitter. I recently started a Substack newsletter, Psychiatry at the Margin, where I explore a lot of these conceptual and critical issues in psychiatry and sciences in detail. And some readers may have seen my interviews for Psychiatric Times for this series called Conversations in Critical Psychiatry.

SPEAKER_02 39:58

Awesome. So I thought that I would just kind of start us off with some light content to get us warmed up.

unknown 40:04

Dr.

SPEAKER_01 40:04

Aftab, is the DSM valid? So I think you know the challenge in answering this question and similar source of the question is I think we have a very binary understanding of validity when we generally talk about mental illness and psychiatric disorders and psychiatric classification. So either something is valid or completely valid or something is invalid and completely invalid. And you know, there's not a lot of uh kind of gray zone or sort of like you know nuance in our thinking about it. But if you look at the actual scientific debates and the philosophical debates around this issue, uh things are not quite so clear-cut. This is because there are different types of validity, and in different types of validity are trying to capture different things. When people ask the question, is psychiatric classification valid? What they normally have in mind is that there are identifiable categories of disease entities out there in nature, you know, identifiable categorical mental illnesses or mental diseases, and whether the DSM classification corresponds to those objective categories, whether there is a there's a one-to-one alignment or a one-to-one matching between the DSM categorization and the categories that really exist out there. The issue is that the scientific research that we have undertaken over the last several decades have shown that this view of understanding psychopathology doesn't seem to make sense. It doesn't fit the scientific data we have. As far as we can tell, uh, we have not been able to identify these sorts of discrete disease entities. And what we instead see is that it's a very dimensional landscape. It's it's a flux, you know, it's it's uh it's a combination of many different possibilities. We are looking at a complex system in which certain patterns emerge that we recognize as symptoms. And so this idea, like we have in infectious diseases that you validate a syndrome by identifying the pathogen that is causing it, that idea of validity applies very poorly to psychiatry and to and to mental health. And so, in a sense, yes, it's not valid, but it's not valid because that's not the model we should be adopting for understanding of psychopathology to begin with. I often, when I'm talking to medical students and psychiatry residents, I often say that instead of thinking about psychiatric illnesses as something like acute appendicitis, where you have a discrete pathological change that has an identifiable syndrome, think of it like uh hypertension, you know, like everyone has a blood pressure, it varies and it's it's a spectrum. We can graph it. There's no natural discontinuity where a blood pressure magically transforms into an abnormal blood pressure. So when we are dealing with this sort of dimensional landscape, we are we are forced to draw a line on it for practical purposes. You know, we have to decide on a threshold. And so the validity of that threshold depends on what we want it to do. The validity of the uh the threshold for essential hypertension is that does it successfully prevent future episodes of cardiovascular illness, stroke, et cetera, right? So we have an identifiable scientific clinical goal, and we use that to draw our threshold. The the challenge in the case of TSM is that right now its thresholds are not really optimized to do anything in particular. They're optimized just based on an expert consensus, but they aren't uh optimized to do any one particular thing, like optimized treatment response or optimized genetics, et cetera. And I think that's where a lot of kind of confusion comes in. And so I would say that DSM has imperfect validity. You know, it it captures certain symptom patterns that we recognize in clinical practice as clinicians, and it sets certain thresholds. That do take into account many considerations, but there is a lot more room for us to do scientific work and optimize the way in which we are setting the thresholds and drawing the boundaries between different conditions.

SPEAKER_02 44:14

I cannot believe that I had never heard that blood pressure analogy before. I am gonna steal that and I'm gonna tell that to everybody who will listen. That is so illustrative of that point. Thank you for that.

unknown 44:24

Dr.

SPEAKER_02 44:24

Atab, so you've really been the tip of the spear in terms of interfacing with anti-psychiatry and defending the fundamental principles of our field. What are some criticisms of the field that you think are warranted and that newly minted residents should be aware of?

SPEAKER_01 44:41

Yeah, I think it just so happened that I ended up in that sort of interface role with uh with the critics of psychiatry. I didn't start off thinking it'll be that I was mainly more interested in understanding the conceptual foundations of the field and the philosophical issues in a more sophisticated way. But um, you know, while I do defend the profession, I do think there are many, many criticisms that that are legitimate and that that we need to take very seriously. I think the biggest one, kind of just, you know, um following up on my earlier discussion is this idea of diagnostic rification. I think ever since DSM III and the and the popularity of the DSM III and its ubiquitous scientific use, we have just kind of adopted this implicit mindset that the DSM somehow reflects the scientific reality, that it provides a sufficient enough basis for us to organize our scientific research. So, you know, for for three decades, a lot of the scientific research where we were doing, we were taking certain DSM groups, sort of like, you know, and comparing them in normal controls, and we are looking for biomarkers, we're looking for biological processes involved. And it started becoming apparent in the 2000s that most of the biological processes involved are of transdiagnostic nature. They don't respect DSM, the DSM boundaries. So we were forced to confront that problem, and this over-reliance on DSM thresholds and boundaries had actually hindered our scientific progress instead of uh you know helping us. So, this idea of attributing more reality to our diagnostic constructs than is scientifically warranted, I think has been a big problem. I think we need to acknowledge that we need to take steps to address it. I think in our communication with patients, in our communications with the public, we have unfortunately relied on a lot of simplistic and misleading messaging. Uh, you know, the message that people have been getting has been in the language of chemical imbalances, has been in the language of brain disorders, sort of like, you know, and without really any conceptual clarity on what these terms are intended to mean, we have been emphasizing that these are legitimate medical conditions. But then what is how is the public supposed to understand what a medical condition is or what the connotations are regarding etiology? So we have neglected, you know, communicating vital aspects of what we mean by by sort of like, you know, by these concepts and terms. And we have also neglected the self-understanding that patients have of their diagnosis and how they understand their own experiences. And that when they understand their experiences through the lens of, for example, the DSM diagnosis, how that changes their self-narrative and self-conception, and how that alters the course of their illness versus if they were to adapt a different sort of understanding. And I think I think that that neglect has had a lot of uh negative impact on people. I think many people have reacted with a sense of betrayal, with a sense of loss of trust, which has been very unfortunate for us. And for example, uh recent book by journalist Rachel Aviv, Strangers to Ourselves, actually documents the ways in which self-understanding of psychopathology influences the long-term course of psychiatric conditions. So this is something that we need to take seriously. I think the way healthcare systems have been set up, there has been an over-reliance on pharmacological treatment. Uh, psychiatrists have increasingly distanced themselves from the practice of psychotherapy and left it more and more to other professions, such as psychology and social work. And correspondingly, psychotherapy has become more and more difficult to access for patients. So we see then an over-reliance of pharmacology, which has had detrimental consequences on the state of clinical care. I think we have neglected the magnitude of itrogenic harm. For example, we have uh we have underestimated the degree to which antidepressants can produce dependence and withdrawal issues, the degree to which they can have sexual side effects, including permanent sexual side effects. Uh, we have neglected many of the harms and risks associated with antipsychotic medications. And I think we have neglected addressing the social determinants of health and public health approaches. Our treatment approaches have been rather stereotypical and very focused on pharmacology and neuromodulation. And that has been unfortunate. So these are, I think, some of the criticisms that I think we need we need to accept and we need to take seriously.

SPEAKER_02 49:19

That being said, are there any common criticisms that you'd be willing to dispel for us here?

unknown 49:24

Yeah.

SPEAKER_01 49:25

I think some of the criticisms we encounter in the public kind of border on stereotypes, that disorder concepts, for example, can only be understood as brain diseases or neurobiological kind of pathologies. And so there's this idea that anytime you call any condition a disorder, whether this is like ADHD or anxiety, that you're positing that somehow the uh brain functioning has gone wrong, that there's a there's a pathology there, that the brain is broken, uh, for example, you know, as some people might say. And so the people interpret that in a very stigmatizing sort of way. And that it doesn't have to be the case. This is not a necessary implication, but unfortunately, there are some people think that that's the only interpretation that that is valid. Uh, I think many criticisms, for example, around the use of pharmacology, I I think there's a sentiment that uh that psychiatrists have intentionally misled the public about the efficacy of these medications, that they have intentionally kind of understated their harms. And there's also the sense that when psychiatrists um engage in involuntary care and voluntary treatment, that there's no uh clinical or scientific rationale behind that, that this is merely a form of social control and nothing but social control. And that when psychiatrists diagnose something as being an instance of mental illness, that they're simply labeling social deviance and social difference as a as a pathology, that there's no reality to psychiatric conditions other than social deviance and social difference. I think those are some of the common criticisms we come across. And uh I don't think they're correct.

SPEAKER_02 51:12

I think most of us who have worked on a psychiatric unit or seen patients in the ED, you know, it's relatively obvious to us that we are not simply stigmatizing people's life choices and values. You know, I think it's it's fairly obvious when you've seen certain populations that there is a functional impairment. And then when you've treated patients long enough, you can see that we clearly have very useful tools to reduce that functional impairment. And so I think that when we talk about things like the problems with antidepressants in America, it's tempting for people to lump all psychiatric medications in with that. And you and I have had the experience of seeing patients who have, you know, severe and persistent mental illness really get their lives back by being on medication like an antipsychotic, which can really help someone who's not functioning really at all in the world to have social relationships, maybe to have an occupation, to have a meaningful life. And so I think that um really clinical experience is what will help people to dispel some of those ideas in their own minds. So sometimes people come to us because they are feeling things that aren't in the DSM. So, like I'm thinking about a patient who feels lost because they're having a career crisis, or a parent who does not feel like the identity of being a parent is very befitting for them. So it can lead to sort of a more existential crisis, a presentation that has factors of belonging, mission, purpose. Do you have any advice for us on how to navigate these conversations, being mindful of the fact that a lot of our patients are not going to present us with very clear stories that have a very specific diagnosis and biological treatment?

SPEAKER_01 52:49

Yeah, I think the important thing to keep in mind is that we don't have to try to fit the patient into our diagnostic classification and schemas. We have to bring our diagnostic tools to the patient experience and try to use them to make sense of the experience rather than try to fit the experience into the boxes that are that are available to us. And the formal psychiatric classification in the form of DSM and ICD, they deal with patterns that are well recognized and that have a certain degree of stability and reliability, and that uh have been shown in you know in to some degree in in research study to be able to track different sorts of validators that we are interested in, for example, family history uh or other sorts of uh scientific findings. So that means that there are many forms of psychopathology, there are many forms of psychological difficulties that are not captured in the formal diagnostic manuals as they exist. Or and that there are there are conditions and there are presentations that that are poorly studied and poorly researched, and for that reason, they have not made it into the formal diagnostic manual. So that's one aspect to keep in mind is that there's a lot more to psychopathology and the ways in which psychopathology presents that than the manual scapture. And the second thing is that there are many psychological difficulties that require some form of clinical help, usually psychotherapy, that are not disorders in the classic sense that we understand them. You know, relationship difficulties are ubiquitous, parentchild difficulties, stressful reactions, difficulties dealing with uh, you know, rare sorts of life circumstances. These are instances that can be quite challenging for the for the individual. And they are instances of what we might call poor mental health, and they may require psychological support and counseling, but we would not consider them to be disorders in the proper sense. And that's that's another reason why the DSM, for example, or ICD doesn't classify them, but they might exist in a section of the DSM we call the V codes, which categorizes clinical conditions that come to clinical attention, but are not necessarily disorders per se. And and psychologists, psychotherapists, and psychiatrists are very used to seeing conditions like that. I think a common one, for example, these days is demoralization and occupational burnout. It's it's not a disorder by itself, but it's it's it's something that many of us experience given the current state of our capitalist economy and the working, working conditions. And the demoralization and burnout can be severe enough that it requires professional help, but it doesn't mean that it's a disorder. It is classified in the ICD as an occupational phenomena, as an occupational problem, but not as a disorder. So we have to, I think, do do justice to the patient experiences. And we also think that diagnosis is just one tool available to us. And sometimes it's not the best tool. Sometimes we have to rely on other forms of clinical description and categorization, and we have to think of ways in which we can formulate the difficulties of the patient, which requires us to have an understanding of the psychodynamic aspects of psychology, cognitive behavioral aspects, and other forms of clinical understanding that are not captured by the diagnostic manuals.

SPEAKER_02 56:16

That's a nice primer for our case formulation episode in the weeks to come. So, my next question for you is when we communicate a diagnosis to a patient, not the formulation, but just the diagnosis, what are we actually communicating to the patient?

SPEAKER_01 56:30

In practice, there's a lot of confusion that surrounds this. This is and the reason for that is that most clinicians, in my experience, don't have a clear idea of what exactly they mean by the diagnostic terms that they're using. And resulting, patients don't have a clear idea of how to understand them. And there's a prospect of miscommunication and reliance on general folk ideas of what something means. So I think the whole setup is very conducive to confusion and miscommunication. I think this is particularly the case when it comes to terms like disorder. You know, when a clinician, for example, tells a patient that I think you have a disorder, you know, what does that communicate to the patient? For for some clinicians, all it might mean is that the clinician is saying that I think you're suffering, I think you're in distress, I think you're you're having a negative functional impact on your life, there is impairment. And we have medical ways of understanding this impairment and distress, and we have medical ways of treating it. And this is what the word disorder is intended to capture. But the patient might understand it in very pathological terms that there's a disease process going on in your brain or in your in your mind, there's a discrete identifiable pathology, there's a broken part, etc. So there are these different aspects and connotations of disorder that you know might not be communicated very well. Similarly, I think when a physician or a clinician says, I think you have major depressive disorder, which is a medical disorder, a medical condition. We don't talk about the relationship between that diagnosis and the social and psychological context in which the patient is experiencing those difficulties. The danger is that the patient might get the understanding that these symptoms are arising from some sort of autonomous biological process that has no relationship to the rest of their psychological life and to their social life, and that these depressive symptoms are, you know, independent of our personality and our social circumstances. When in fact, you know, depression, symptoms of depression, anxiety, many other mental illnesses, they're heavily context dependence. They're they're they're value laden, they have they have phenomenology that we can explore, we can discuss, they have, they have hidden meanings that get that can be analyzed. And so the risk is that we alienate patients from their own emotional lives and from their own social circumstances if we do not communicate the relationship between the diagnosis and the context, which you know, in most cases clinicians are not doing.

SPEAKER_02 59:10

Hit the nail on the head, Dr. Aftab. I think there's a real threat in not explaining this well to a patient because it can allow a patient to say, Oh, I have this diagnosis and I have this doctor here, and he's going to fix me. You know, he's gonna prescribe a medication, and my life is suddenly gonna get a lot better because I'm no longer going to have this disorder. And it can really get in the way of progress in treatment because it can really prevent someone from feeling like they have self-efficacy over their situation, because there's some external, nefarious force that is burdening them, you know, and of course it's bio, psychosocial, spiritual, but there's a real threat in allowing people to simply name and externalize something. I think this comes up a lot across the entire diagnostic spectrum. And especially lately, as people are consuming a lot more popular culture on psychiatric diagnoses and often not with the appropriate nuance included.

SPEAKER_01 1:00:01

Exactly. I think we are seeing this usage of diagnostic terms across social media, on TikTok, and and the and the negative ways in which you know uh it is being used.

SPEAKER_02 1:00:12

Okay, I would like to pull out one caricature of psychiatry that's mentioned in an article by Dr. Daniel Moorhead, where he's sort of giving what he sees as common criticisms and laying them to rest. So he's sort of giving a defense of the field. Now you wrote a really thoughtful response and covered many of the finier points, but I want to talk about one of the broader assertions. So Moorhead says that one of the most common critiques of our field is quote, psychiatrists are biological reductionists and pill pushers who diagnose and prescribe everyone they see regardless of their condition. So I have a couple questions for you on this. The first one is, is that true?

SPEAKER_01 1:00:49

So this is a question that can be answered by like a simple, like, you know, yes, no um answer. Uh I think there is some truth to that. And it's important for us to understand what that is. One is that even if this is this is not a true portrayal of how psychiatrists think and how they act, we have to keep in mind that this is how we can come across to patients who don't have access to what we are thinking and you know our clinical reasoning. Because from the patient perspective, if they show up to a psychiatrist with their clinical, you know, psychological difficulties, some sort of problem they're having, and the psychiatrist spends just like you know 10, 15 minutes with them, goes through a list of you know symptoms, you know, kind of like a checklist sort of approach, gives them, you know, oh, you have generalized anxiety or you have major depression, and it's uh it's a medical disorder, and here's your you know prescription for that. If if that's all they do, the sense the patient is going to leave it, you know, that, oh, you know, they're not interested in my psychological life, they're not interested in making sense of my symptoms, they know, uh, they're not interested in exploring them. All they're interested in is you know, checking tick boxing the symptoms, giving me a diagnosis, and giving me a medication. So, so one is that you know, there's a reason why this stereotype exists. And the the reason this stereotype exists is that because a lot of patients are leaving their clinical encounters with this impression, you know, unfortunately, whether we like it or not, we're we're practicing in a lot of you know uh system constraints, you know, we don't have a lot of time, we don't have a lot of resources, but uh but that's something to be mindful of. The second thing is that, yes, most psychiatrists I know are quite open to psychotherapy. Um, most psychiatrists I know work with some sort of a bio-psychosocial kind of formulation model, but it it is the case that that many psychiatrists, I think, overestimate the efficacy of medications and underestimate the therapeutic value of psychotherapy. And it is the case that many psychiatrists um overestimate the biological contributions to mental illness, and they heavily conceptualize psychological phenomena in terms of neurological phenomena, in terms of sort of like brain processes, you know, as biochemical processes, genetic processes, or you know, brain circuit disorders, etc. So there are these tendencies that even if we are not pill pushers in the absolute sense or reductionists in the absolute sense, there are these tendencies towards overusing pharmacology and tendency towards over-attributing causality to biological processes that we need to be mindful of. That's awesome.

SPEAKER_02 1:03:42

That that is so clear and concise for us. The next follow-up question on this would be as a faculty member, what do you do to ensure your graduates don't fit that caricature?

SPEAKER_01 1:03:53

I I've been involved uh with teaching for for several years now, ever since I finished my own training. And there's only so much any one individual can do. But the thing that I most focus on is having these conversations, is that I kind of openly bring up these questions, I ask these questions to trainees, and we openly talk about it and discuss them. Because I think that the biggest issue we have had in psychiatric education is that there has been no systematic way in which trainees have explored the conceptual and philosophical and theoretical side of psychiatry. Um, these questions have been left unaddressed. So even though there has been a lot of academic work done on this, a lot of philosophical work done on this, there have been many debates in journals and in books, but none of that makes it into psychiatric education. And so the trainees are, you know, they they learn the DSM criteria, they learn the clinical interview, clinical assessment, formulation, but they never get an opportunity to step back and say, well, you know, if I if I say that a condition is a disorder, what does that mean? What am I saying? What sort of judgments am I making? You know, how do different forms of sociocultural norms influence my decision about calling something a disorder? Or how do system issues kind of impact the treatment approaches I'm using? Or how should we approach the self-understanding and phenomenology of psychiatric conditions? So I think we have to tackle these problems head on. We have to, I think, discuss them, we have to critically analyze them. And I think if we start doing that, asking these questions and getting people to think about them is a big first step and um and a necessary one. And I've been a big advocate of what I call conceptual competence, that just as we expect competence in in clinical practice, and nowadays we expect competence in navigating cultural differences, and we expect structural competence that clinicians should. An understanding of how structural factors impact medical care. Similarly, I think psychiatrists and physicians in general should have conceptual competence that they should have a basic understanding of the nature of the concepts that they're using and the ways in which those concepts are applied and debated in the field.

SPEAKER_02 1:06:19

And I know you're certainly driving the field more toward that direction. And I hope that our listeners will consider subscribing to your Substack or following you on Twitter or anything to get more kind of exposure to these deeper ideas. And that's why we're starting Psychiatry Bootcamp here, because just finishing medical school, we've learned about diseases and treatments and biological markers and imaging studies. And that's not very helpful to us in psychiatry. And the treatment of someone who is feeling down and sad because they're having a divorce is very different than the treatment of someone who has a tumor growing in their intestines, which really doesn't have a whole lot to do with how their relationships are going in their life, you know. There are other social factors that are involved in that, but not so much how they're communicating with someone and the difficult vicissitudes of life that they're having to endure. You mentioned demoralization and capitalism earlier. And when I think about why psychiatry has been placed into the place that it is today in 2023, the question is who's driving the bus? You know, what interests are we pursuing in the industry of healthcare? And are we pursuing the best interest of the patient? And my hope is that by listening to Dr. Francis and listening to you, our audience is going to always remember that we need to treat our patient as our number one priority, always follow the patient, not take the manual out of the context for which it was intended, feel empowered to move into the psychological, social, spiritual, cultural realms, and really make sure that they're taking a whole person approach to treatment.

unknown 1:07:55

Dr.

SPEAKER_02 1:07:55

Raftab, do you have any parting thoughts for our listeners?

SPEAKER_01 1:07:59

I think you all you offered an excellent summary, and I'll I'll just reiterate that it's very important to look at the whole person and to contextualize our symptom clusters, our diagnosis in the larger context of their psychology and in the larger context of their development and their life. And if we don't do that, then we are setting our patients up for failure in many ways.

SPEAKER_02 1:08:25

Thank you so much for being done for your time and looking forward to talking to you next time. Thank you so much. Thanks for listening to this episode of Psychiatry Bootcamp. Special thanks to the Behavioral Health Education Center of Nebraska for their support. If you have any questions or feedback from me, you can email me at Psychiatry Bootcamp Podcast at gmail.com or reach out to me on Twitter. Of course, this podcast is not intended to be used in medical advice or in any legal proceedings whatsoever, including to establish a standard of care. This podcast is intended only as a supplement to a complete, accredited psychiatry residency and is grossly inadequate to rely on for medical decision making. It is intended to entertain and inform you should always rely on your own clinical judgment when making medical decisions. And contact your physician for medical advice.