Why Holistic Mental Health Assessment and Care

Why Holistic Mental Health Assessment and Care

What is Holistic Mental Health Care and Why is it Critical to Mental Health Care and Feeling Well?
There are many reasons why a comprehensive evaluation with a broadly trained clinician can be crucial to getting the help you need. Your psychological well-being is shaped by multiple inter-related systems (medical, psychological, social, psychiatric, behavioral, lifestyle, spiritual, etc). A clinician trained to understand and work within multiple systems has a better chance for a global understanding of the issues affecting you, a better chance for developing and implementing a multi-system plan to address these issues and ultimately, a better chance of helping you to make lasting changes. 

"Holistic" means “emphasizing the importance of the whole and the interdependence of its parts”.  My extensive training and experiences with conventional (allopathic) care for the mind and the body combined with my experiences in alternative settings (relying more on natural manipulations of the same physiological systems) and my extensive psychotherapy training, allows me to provide truly holistic mental health care. I sought out 6 years of post medical school training, in psychiatry and internal medicine because of my fascination with the mind-body connection 20 years ago, but now I realize that there are even more systems in play than just the mind and the body.

When you go to a psychiatrist for a psychiatric evaluation, a psychologist or therapist for a psychological assessment, your primary care doctor for antidepressants, a life coach for lifestyle issues, you have made the decision for yourself that your problem is chiefly due to a psychiatric illness (psychiatrist, primary care doctor), a psychological problem (psychologist, therapist), a lifestyle issue (life coach) or some sort of toxicity in your environment. You have also opened the door to being possibly misdiagnosed (a potentially life-threatening situation, see below) and to having your treatment options limited right off the bat.
This is analogous to seeing an vascular surgeon for new-onset pain in your leg because you think it might be due to decreased blood flow, rather than starting with your primary care provider who has the ability and experience to diagnose and treat most of the causes of leg pain and would be best able to send you in the direction of the correct specialist for appropriate treatment, should you require one. My training allows me to examine all of these systems; my experience has shown me how they all inter-relate (see below); my practice structure gives me the time and opportunity to really get to know you. A complete multi-system assessment and a multi-pronged wellness plan within one practice setting is the essence of holistic treatment. If you require specialized services outside of my scope of training, I will coordinate this and work as a partner with all of your clinicians, as the hub for your mental health care.

I have seen again and again that while the initial source of mental distress can be one dimensional, the inter-relation of all of the systems (medical, psychological, social, psychiatric, behavioral, lifestyle, spiritual, etc), quickly leads to multi-system disruption, requiring a holistic approach to regain balance. In other words, while the source of the stress is initially confined to just one of the many systems, i.e. a medical problem (diagnosed, undiagnosed, treatment-related, etc), a psychological issue (haunted by past experiences, rigid behavioral responses, etc), a. psychiatric illness (disruptions in brain functioning, etc), a lifestyle imbalance (the body is deprived of something it needs to rejuvenate, etc), a substance-related disorder (toxins disrupting brain and body function), a nutritional deficiency, a social struggle or even a spiritual void (loss of meaning, etc), the stress in this one system will exert its effects globally in a very short period of time, resulting in multi-system disruption. Multi-system disruptions are incredibly stressful and almost always affect medical health sooner or later; we know now chronic stress and mental health conditions can worsen the prognosis and course of a variety of medical conditions (heart attack, stroke, cancer, diabetes) and it can even increase physical pain. The final common pathway of multi-system disruption can have very nonspecific symptoms, physical and mental: fatigue, poor sleep, generalized muscle tenderness, headaches, poor focus, gastrointestinal upset, worrying, lack of enjoyment, sadness, feeling on edge, no zest for life. It’s no wonder that people with these symptoms sometimes don’t know what is wrong and will sometimes see one provider after the next, looking for help, ending with a mental health clinician because others didn’t weren’t able to find something to treat. Multi-dimensional assessment and treatment is vital to this person's recovery.

Below you will find some specific examples of how perturbations in one system can lead to multi-system disruption and there are many more:

A person can have non-specific physical symptoms initially due to a medical condition (diagnosed or undiagnosed, even medication-related) and will develop some psychological symptoms in response to the losses associated with not feeling physically well (sadness, lack of enjoyment, nostalgia for the past), often social withdrawal (not wanting to be burdensome), behavioral symptoms to modulate the physical symptoms or provide new sources of enjoyment, like less physical activity, perhaps overeating or overuse of painkillers. Then feeling ill, sad, nostalgic, isolated and lonely, coupled with pain pill dependency can then lead to an inability to work and other issues associated with major lifestyle change (loss of identity, loss of purpose, loss of financial security, etc). Now, a person is on the road to existential crisis, i.e. loss of purpose or meaning for life, and well on their way, especially with a genetic predisposition, to a diagnosable, full criteria psychiatric condition like panic disorder or depression. But really, this person has a multi-system imbalance requiring holistic care for her to heal.

Unresolved childhood traumas cause huge disruptions in multiple systems which cause long-standing global problems. As a result of childhood abuse, there are changes in the way the body and the brain react chemically to stressors as an adult, involving stress hormone release. This dysregulation can lead to diabetes, cardiovascular disease and immune deficits, amongst other problems. Sleep is chronically disrupted, and this can lead to chronic fatigue, decreased motivation and sugar craving. Dissociation and deficits in coping skills lead to problems in school, relationships, at work. Trust issues interfere with developing close friendships and intimacy, not allowing a balanced lifestyle to develop. Low self esteem, guilt and feeling unsafe can cause a person with a history to childhood abuse to feel disconnected and different from other people. Depression, anxiety, anger, numbness can become dominating features of a person’s life. Misguided attempts to feel better can lead to binge-eating, compulsive behaviors, substance abuse, self-harm. A diagnosis of borderline personality disorder can lead to stigmatization rather than help. At this point, again, holistic multi-system care is vital for recovery and can result in remarkable transformations.

Someone with a purely psychiatric disturbance, for example, hearing voices, often develops physical symptoms in response to the stress of the underlying psychiatric problem (muscle tension, headaches, poor sleep, fatigue, etc), has behavioral issues as he/she tries to decrease these voices with distraction or substances or eventually just gives into them and behaves in an inappropriate manner. Social problems develop because of difficulty focusing on the external world; medical issues develop because of a higher risk for diabetes or metabolic issues in people with schizophrenia and bipolar disorder (genetically and due to the medication effects) and difficulty with self care. Lifestyle disruption becomes complete as it is too difficult to hold a job, too difficult to hold on to social supports, mindfulness is not possible and the external world disappears as the internal world becomes increasingly hostile. While a visit with a psychiatrist for medication is a good first step; it is only a first step. This person also requires a holistic care plan to get her life back. 

Unbalanced lifestyle issues ( for example, all work and no play versus all play and no work) can lead to behavioral disruption (perfectionism/rigidity versus lack of boundaries/drug and alcohol abuse), psychological issues (feeling others lack competence versus inability to commit), social issues (anxious when not achieving versus inability to relate to others who are “not fun”), spiritual issues (feeling adrift due to work burnout versus feeling adrift due to being unanchored), medical issues (eating disorders, medical effects of substances, stress-related illness) and finally, psychiatric issues (full-blown anxiety disorders developing after an unpreventable mishap usually versus depression from being increasingly detached from others). While, this person needs lifestyle balancing, that may not be enough at this point. 

I am going to include a section on eating disorders at some point , so I will be brief here: It is very clear that nutritional choices very much impact well-being and the ability to experience pleasure and to feel relaxed. Neurotransmitter, vitamin and mineral cofactors levels, fats available for neural membranes and myelination of nerves (nerve conduction) can be affected by diet and eating disorders, with resultant psychological and even psychiatric consequences. Come see me and we'll talk more about that!
In addition to the probability that by the time one seeks help, a disturbance originating in any system has spread to the others, another reason for a comprehensive exploration by a holistic clinician is that a serious underlying source of the disturbance can be missed by a one-dimensional practitioner and remain untreated, at the very least impeding recovery and possibly becoming life-threatening. It is not always easy to pinpoint the source of distress as a medical disease, a medication reaction, a psychiatric illness, or psychological symptoms related to life stressors. When the source is one of the former, a missed diagnosis can have very serious consequences. 

I can provide a classic example from my own personal experience:

I developed magnesium deficiency from taking prilosec for gastroesophageal reflux before the FDA issued a warning about the possibility of this occurring due to magnesium needing an acidic stomach for proper absorption. I knew something was terribly wrong: I felt unbalanced when I turned my head quickly, my asthma was much worse, I had almost daily migraine headaches, I had big painful knots in my neck and back, I had bursts of palpitations, my hearing decreased, and I woke up every morning with severe abdominal cramping. I saw my doctor and was scheduled for an exploratory laparoscopy to rule out endometriosis as a source of the abdominal pain, as we were prioritizing what to treat and the other symptoms were not felt to be related; they were treated symptomatically with inhalers, migraine medication, stretching, etc. But, I also felt very anxious for no apparent reason. I had a difficult time getting organized and I had started to limit my driving because I didn’t feel safe. These are all classic symptoms of magnesium deficiency, but this was a condition not recognized by allopathic medicine until after the FDA issued its warning. This warning was issued after people on these common medications for gastresophageal reflux started to develop seizures.

I actually diagnosed the problem myself. In a lot of ways, it looked psychiatric, but being a psychiatrist, I knew that it wasn’t. Being an internist, I thought I had some kind of systemic disease like an autoimmune disease or disseminated valley fever. In my mind, I wondered if I had a systemic disease and it was exacerbated by a variety of stressful events which had occurred fairly recently in my life and my lifestyle was certainly unbalanced (see the lifestyle balance section). I wondered if this was how my life was going to be. Then the pieces started to come together. I knew that the naturopaths have long recognized that an acid stomach is important for nutrient absorption, so I looked at what nutrients could become deficient with an alkaline stomach, I discovered that magnesium was an important one. I looked up the symptoms of magnesium deficiency and while it was listed as very rare, the symptoms matched-all of them! Then, I searched proton pump inhibitors and magnesium deficiency and viola! There was a small study showing a link. I started the magnesium, stopped the prilosec and upped my intake of leafy green vegetables and within a week, I was a different person. Then, the FDA warning came out. I was close to having a seizure! Not to mention inappropriate surgical exploration! If I had not been a psychiatrist, I might have gone to one and ended up on daily doses of addictive anti-anxiety medication!

While no one can claim to be able to diagnose and treat everything, a wider exposure increases the odds of a clinician recognizing other possibilities and possibly initiating a targeted literature search, if your condition is rare. (Ask me about the diagnosis, treatment and miraculous recovery of Barb, my beloved French crested chicken, which occurred in a similar manner to my own.)

Very few psychiatrists have had board certification in internal medicine. This involves being part of a general internal medicine team for 3 years, diagnosing and treating hospitalized patients with complex medical issues and supervising the medical team for a year, in addition to providing primary care. So, with my dual training, I have a better ability to discern sources of problems resulting from medical conditions and medications used for medical conditions which can cause specific-appearing psychiatric or psychological conditions. I have also seen first-hand the psychiatric side effects of common medications, even antibiotics, and how medical illnesses can present psychiatrically. While, I can not guarantee that I can recognize all of these conditions, I have extensive training and experience in recognizing symptom complexes and red flags associated with most of them, and I have the curiosity to find answers. When I spent 5 years as an inner-city psychiatric emergency room attending in Philadelphia I saved a few lives by recognizing diseases which could have landed very medically ill people inappropriately in a psychiatric facility where they would not receive the life-saving medical care they desperately needed. I have had similar, but less dramatic experiences with my outpatients in Tucson. 

Additionally, many of the conditions considered to be primarily psychological (stress) or psychiatric can be associated with major effects on the body, producing symptoms which can masquerade as medical diseases (stress causes a host of physical symptoms as mentioned above; people with panic attacks look like they are having a heart attack, people with bipolar disorder can have severe appetite disturbance, circadian rhythm alterations and disabling fatigue) and they can make medical problems worse. Emotional stress can upregulate pain pathways and literally increase a person's pain. Medical conditions cause symptoms and require treatments which affect quality of life and cause psychiatric problems. My interest in the mind-body connection is what led me to pursue full residenciesall in both internal medicine and psychiatry. For me, this is where it started. I am very competent to help you address these issues.

Insurance companies for the most part dictate the sort of services clinicians are able to provide (see my section on the Pitfalls of Using Insurance to Pay For Mental Health Care). Psychiatrists are fully trained in psychotherapy, but insurance companies won't pay for them to do it. Sometimes they will not pay for a therapist's care unless the patient is on medication as well, whether it's appropriate for the patient to be on medication or not. Holistic care and in-depth assessments are not covered. How can a psychiatrist monitor a patient's entire mental well-being during a 15 minute med check? By not succumbing to the bottom-line mentality of the insurance companies, I am able to really look at your problem and address it most appropriately; I have the kind of training which allows for a comprehensive exploration of all of systems causing your distress and I have to the time to present all of the options for your care to you, not just pharmaceutical options. 
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