Synergies In Treatment: For Psychiatrists, Therapists, and Everyone

SYNERGIES IN TREATMENT #1

What is Emotional Wellness? Just as the concept of physical wellness doesn’t necessarily mean that exercising and healthy nutrition will get rid of your diabetes or hypertension (although it sometimes will) an emotional wellness program won’t necessarily cure someone’s mood disorder.  Such a program might however help prevent someone from getting depressed in the first place, or keep them from relapsing once their episode is treated.

Psychopharmacology and psychotherapy are very passive on the part of the patient. In most types of psychotherapy, many patients feel that they’re doing their job simply by showing up once a week for a 45-minute session.  These sessions total a drop in the bucket of their life experience, thus having minimal impact, while they remain caught up in their usual patterns of day by day living.

We as psychiatrists are in the unique position of understanding mental illness psychologically as well as biologically.  We’ve also been trained to understand the environmental and familial contributions to mental illness, as well as the importance of establishing and maintaining healthy relationships, developing a healthy sense of self, emotional support, and other aspects of emotional wellness. The term “Biopsychosocial” psychiatry comes up with varying frequency.  The biological, psychological, and social spheres are all important in our work with patients.  These areas are all interrelated, and helping our patients strengthen themselves in each of these areas strengthens them in the other areas.  The best example is that of regular physical exercise contributing to improved mood and emotional wellness, and conversely, that when patients learn to value and take care of themselves, they exercise and become more active.

However what is often neglected by our profession is an important fourth dimension, that of the Spiritual.  Just as the other three spheres are interrelated aspects of life, spirituality is important as well.  The term “spirituality” is defined here as a sense that has to do with an awareness of one’s self as a part of a larger universe, the awe in what is known and what is not known, with or without a higher power.  For an individual, spirituality may or may not include an organized religion.  For many, spirituality is an appreciation of nature or the laws of the universe.  Either way I believe that spirituality is an important fourth component that we must help our patients enhance and maintain in order to have a full and balanced life.

We must look at our roles in the broader sense of advocating for our patients’ understanding and utilization of methodologies that can address all four of these areas.  Whether we ourselves prescribe medication and do psychotherapy or we split the treatment, it’s important that we provide our patients with a perspective that helps explain their mental illness and how it relates to their physical health, relationships, environment, and spiritual needs.  From there it’s only a half step to demonstrating to them how by taking better care of these needs will help them to be more emotionally well. They probably need help and guidance in some of these areas, such as a nutritionist or fitness coach, family or couples’ therapy or workshops, or perhaps social skills training.  They may benefit from consultation with clergy, getting more involved in church, a nature organization, or an organization to save the planet.  Many of our patients have motivational issues and/or self-worth issues in the psychological realm that with treatment will improve each of the other areas.

It is important to set goals early in treatment so that the medication, the psychotherapy, and the patient are all working in the same direction.  This goal-setting puts in motion the creation of synergy in treatment.  Toward the end of the initial evaluation, we summarize our goals for treatment and discuss the concept of bringing together what we’re trying to do with medication as well as with psychotherapy.  I explain that the more the patient does between the sessions towards our goals (such as homework or reading) the less they will need the visits to me and the less medication they will need.

In addition, there is the concept that once we get in the swing of routine self-care and maintenance, then slipping out of healthy routines becomes an important early warning sign of relapse.  The routines become a buffer, a layer of protection.  Active, lifelong mindfulness and maintenance of our body’s needs becomes a new backbone or foundation for a life as healthy as we can make it.  Of course that may include the need for lifelong medications for certain illnesses.

We want our patients to leave the office with goals.  These goals may include reduction or elimination of depressive episodes or panic attacks, establishing healthy sleep patterns, understanding their emotions, improving self-esteem, and/or self-care.  What can patients do between sessions to add to the synergy? Lots.  If using CBT, you can give  homework assignments such as mood logs and relaxation exercises.  There are books that help readers make their own relaxation tapes, CDs, or podcasts on mindfulness, which patients can listen to as much as possible every day. Let us further expand the concept of  homework to include a comprehensive approach that encourages a total lifestyle change, in order to build a new foundation for life, which would include healthy nutrition, regular exercise, outdoor recreation, and possibly yoga or other body/mind work.  It would also include regular attention to psychological maintenance, such as hobbies, creativity, challenges, attention to important values and priorities, and love.  There are also social needs which require maintenance.  Repairing damaged relationships where possible, deepening current ones, and making new meaningful relationships require work and prioritizing.  We can also discuss the importance of addressing spiritual needs.  Establishing these new and healthy routines is hard work. Most of us are not taught growing up how to balance our lives.  Other peoples’ needs, making money, looking good often come before taking care of our biological, psychological, social, or spiritual needs.  The goal of Wellness is doing what we need to do for ourselves on a regular basis as a priority in life.

Many of these are new concepts for us as psychiatrists to think about:  A Biopsychosocialspiritual perspective; setting specific goals for the future;  patients being active in working toward these goals between sessions;  establishing and maintaining balance and wellness in life.  There’s much more that we can do to create synergies between the goals of psychiatric medications and the goals of psychotherapy.  When we add to that dual treatment, we’re well on our way toward the patient taking charge of their life.  In this column in the future I hope to get into more details and ideas about how to create and enhance synergies to help move our patients forward.  Next issue: Synergies In Treatment: Medication Effects and Psychotherapy.

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