Join host Dr. Jonathan Weinkle as he welcomes psychiatrists Dr. Warren Kinghorn and Dr. Abraham Nussbaum on Healing People, Not Patients. They explore their book Prescribing Together, advocating a relational approach to psychopharmacology that prioritizes alliance-building, understanding patients’ stories and the meaning of symptoms over the “dispenser model” of simply handing out prescriptions.
What if prescribing medication meant more than following an algorithm, it meant walking alongside patients in their stories?
In Episode 15 of Healing People, Not Patients, Dr. Warren Kinghorn and Dr. Abraham Nussbaum discuss their co-authored book Prescribing Together: A Relational Guide to Psychopharmacology. Drawing on the Hasidic story of the Turkey Prince, they challenge the dominant “vending machine” model of psychiatry and emphasize meeting patients where they are, understanding the personal and narrative
meaning of symptoms like hallucinations, depression, or emotional dysregulation.
The conversation covers collaborative prescribing for conditions including schizophrenia/psychosis, depression (and SSRIs), eating disorders, bipolar, and borderline personality disorder. They highlight the importance of diagnosis as a provisional tool that should open helpful pathways forward, the value of social prescribing and therapeutic relationships, de-prescribing when appropriate, and reclaiming psychiatry as a deeply human, meaning-centered practice.
Top 3 Takeaways:
About the Show
Healing People, Not Patients explores ways to enhance medical practice by infusing it with compassion, humanity, and a deeper sense of purpose, aiming to help healthcare professionals rediscover the "soul" of their work. Framed around the four questions of the Passover Seder, it probes how to transform medicine for the better, promoting an empathetic and supportive approach that empowers patients to create meaningful, sober lives, while drawing on Jewish teachings about community and friendship.
"Our theme song, "Room for the Soul," is available on Bandcamp at https://jonathanweinkle.bandcamp.com/track/room-for-the-soul."
About the Guests
Dr. Warren Kinghorn is a psychiatrist and theologian, and co-director of the Theology, Medicine, and Culture Initiative at Duke Divinity School. He is passionate about psychiatry as a relational practice rooted in practical wisdom and human connection.
Dr. Abraham Nussbaum is a psychiatrist at the University of Colorado School of Medicine and Denver Health, where he serves as Chief Education Officer. He is a writer and educator who emphasizes narrative approaches in medicine and the importance of restoring patients’ stories.
Together, they are the authors of Prescribing Together: A Relational Guide to Psychopharmacology.
Connect with the Guests
Dr. Warren Kinghorn: warren.kinghorn@duke.edu | Duke Faculty Page
Dr. Abraham Nussbaum: Abraham.Nussbaum@dhha.org | abrahamnussbaum.com/contact
About the Host
Dr. Jonathan Weinkle is an internist and pediatrician who practices primary care at a community health center in Pittsburgh. He strives to be a "nice Jewish doctor" focused on patient-centered healthcare, emphasizing effective communication and holistic well-being.
He teaches the courses, “Death and the Healthcare Professions” and “Healing and Humanity” at the University of Pittsburgh, authored the books Healing People, Not Patients and Illness to Exodus, and runs ‘Healers Who Listen’, where he blogs on healing and Jewish tradition. Once an aspiring rabbi, he now integrates faith and medicine to support other physicians and his own patients.
🌐 Website: healerswholisten.com
🔗 LinkedIn: linkedin.com/in/jonathan-weinkle-3440032a
📸 Instagram: @HealersWhoListen
📘 Facebook: @JonathanWeinkle
[00:00:00] There's an old story usually attributed to Rabbi Nachman of Breslov, one of the great Hasidic masters of the 18th century. He used to tell about a prince who became mad and thought he was a turkey. The prince would sit under the table naked, eating the bones and scraps and pieces of bread that had fallen on the floor, just like a turkey would.
The physicians, the psychologists, and all of the other curers in the king's court eventually gave up hope he was mad beyond repair. The king was very sad. Then one day, a sage arrived in the court and said, "I can cure him." And the sage did something unusual. He undressed and also sat naked under the table next to the prince, also picking up crumbs and bones.
"Who are you?" asked the prince, "And what are you doing here?" "And you," said the sage, "what are you doing here?" "I'm a turkey," said the prince. "Oh, I'm also a turkey," said the sage. So [00:01:00] they sat on the floor together for a while until they became good friends. One day the sage signaled the s- king's servants to throw him his shirts.
He said to the prince, "So what if you're a turkey? Does that mean you can't wear a shirt? You can still wear a shirt and still be a turkey." So they both put their shirts on. After a while, the sage called for their pants. Once again, he said, "What? A turkey can't wear pants? You can wear pants and still be a turkey."
He kept going until the prince was wearing all of his clothes again. Then he asked for regular food off the table on plates with silverware. The sage turned to the prince, he said, "What? Just because you're a turkey, you can't eat off of a plate? Hot food with a fork and a knife? You can be a turkey and eat hot food with a fork and a knife.
It's okay." So they both ate. And finally, the sage said to the prince, [00:02:00] "Turkeys have to sit on the floor? Where is it written that turkeys have to sit on the floor? The turkeys can sit at the table, too." And so they climbed up in the chairs and sat at the table. And eventually, the prince came back to his senses and realized he was a prince, not a turkey.
Now, I have to admit, this sage had some pretty unconventional methods. I don't think you'd be allowed to practice psychiatry that way in the twenty-first century. But the story teaches a valuable lesson about meeting people with mental illness where they are, understanding what the symptoms of those illnesses mean to them.
And instead of attempting to fix it by foisting a medication on them, getting into their life world, making an alliance with them, and slowly but surely rehabilitating them to where they feel like they can function in society again My guests today, Warren Kinghorn and Abraham Nussbaum, are both [00:03:00] psychiatrists who also have a different approach, one that also centers on getting to know their patients and not immediately reaching for the prescription pad before they decide how they're going to help someone.
They're interested in helping people rebuild their lives, regain meaning, even if they don't completely cure the psychiatric illness. I hope you'll stick around for this episode and hear about their approach that they call prescribing together. Stay tuned
[00:00:00] All right. Welcome back, everyone. I am joined today by a couple of colleagues. Dr. Abraham Nussbaum, who is a psychiatrist and, works both at the University of Colorado School of Medicine and at Denver Health, where he is the, chief education officer.
and Warren Kinghorn, who is a psychiatrist, a theologian, and co-director of the, Theology, Medicine, and Culture Initiative at Duke Divinity School. And they are also co-authors. And the book that they co-authored, which is the reason that I invited them to be with us today, is called Prescribing Together: A Relational Guide to Psychopharmacology.
I picked this book up directly from Warren at a conference about three years ago, and it sat on the shelf like books you pick up at conferences do. And then I read it last spring, and I was fascinated. so if you'll indulge me for 30 seconds while I explain why. my late father-in-law, who passed last December, was a psychiatrist who was very much of the old school.
he trained in medicine [00:01:00] in the Soviet Union, but trained in psychiatry here in the US. and he still did, throughout his entire career in private practice, hour-long appointments. He often did some psychotherapy as a part of his conversations, was very meticulous in his workups, and did a lot of negotiating with his patients, or at least I would describe it as that way.
He would have told me that he didn't negotiate with anybody, because that was his personality. but seeing a book like this that pushes back on what you describe as the dispenser model, the doctor as vending machine, was really a breath of fresh air. And so I wanted to have you come on and talk with us about it.
It's really great to be with you, Jonathan. Thanks so much. I love that your father-in-law is a psychiatrist. That's amazing So the first thing that I wanna do is set the scene, which is that you take most of the major psychiatric diagnoses, bipolar disorder, obsessive compulsive disorder, eating disorders, and devote a chapter to each, leaning heavily on research, but [00:02:00] trying to paint a picture of what it's like to rather than have somebody come in and say, "I've got this," and basically, work through an algorithm and say, "Okay, this is the medicine, this is the dose.
Here you go. See you back in a week to make sure it's working." and rather take that person's experience and attempt to understand what they're going through and collaboratively prescribe. Work through it as, as I do a lot in primary care, deciding together what's best. Yeah. So I wanted to have you talk a little bit about how you arrived at that model.
and then I have several specific questions about chapters that really caught my attention Yeah, I could maybe speak first and then Abraham could speak to that question of, like, why did we do this work to begin with? as is Abraham, I'm a psychiatrist. I love being a psychiatrist.
When I first experienced psychiatry in medical school, I was actually turned off to it. I decided to do something [00:03:00] else instead. I remember I was at Harvard Medical School and we went down in our second year, an afternoon a week to Mass General in Boston, and we had fantastic teachers who really did teach me the basics of, clinical diagnostic evaluating.
But it was done in a way that was just very, by the book for the DSM. We learned how to do structured interviews, we learned... We had to free write DSM criteria sets from memory for the exam, around, major depressive disorder or bipolar I disorder and so on. And the interviews felt very formulaic.
It felt like we were just trying to identify symptoms that patients had and to get through it in a certain amount of time. And I see the importance of that. I guess I'm glad that I was trained to be able to do that, but it wasn't very life-giving at all. So I decided, "I'm gonna, I'm not gonna do psychiatry.
I'll do internal medicine, maybe palliative care." And it was only later that I came back into psychiatry and began to realize that, if that's what psychiatry is just identifying symptoms that patients have and [00:04:00] collecting those symptoms and assigning diagnoses and then reaching into our toolkit of evidence-based medications and therapies to treat those diagnoses, then, one is that's, frankly in many cases not very hard to do.
Mm-hmm. It's the kind of thing that medical students like I was once could be trained to do fairly well. Frankly, AI platforms could be trained to do fairly well. but it's also not the core of what psychiatry is at its base, which is developing trusting relationships with people who are going through challenges.
They might be challenges in their thinking, might be challenges in their feelings, might be challenges in their relationships or in their behaviors or in their way of being in the world. and having the kind of practical wisdom that's, that draws from decades and even centuries of experience of those who've gone before- to say, "How can I walk alongside this person in front of me and be of assistance to this person and help this person to find freedom and agency?" Mm-hmm. And when psychiatry is [00:05:00] understood in that way, it's an amazing discipline. It's so life-giving and it has so much to bring to people. But you have to get out of what we call the dispenser mindset, and I think we could talk more about that in the context of the conversation.
Yeah, absolutely. Thank you for that explanation. So Abraham, I'm hearing Warren talking about the person's way of being in the world, the person's relationships, the person's experiences. I first met you, although we didn't actually meet 'cause it was the 2021 Conference on Medicine and Religion, and it was all over Zoom.
but I first encountered you in a workshop about writing in medicine. and I feel like you as a writer and a storyteller this is very much of a piece with that part of you this, way of approaching psychiatry. walk me through a little bit about how that narrative approach plays into some of the insights in the book.
Warren talked about the limits of a model of prescribing medications and dispensing [00:06:00] medications, and part of that is that he talked about this question of identifying symptoms, abstracting them into a diagnosis, and then matching them to a treatment. Again, we're thrilled about evidence-based medicine and the advances of psychiatry in the last 50 years.
The trouble is that when you abstract those symptoms, you miss all of the context and the depth of them. Symptoms don't exist separate from the life of the person, and that's why it's important that we think about their story, and we have to think about this question of how this person fits into the world.
And so psychiatry, properly understood, is a narrative art A big thing that people come to us seeking psychiatric care for is that there's a rupture in their narrative. And like any other ruptured narrative, the question is, does it mean that you need to repair that narrative? turn towards a new narrative, right?
These are the kinds of questions you have to ask with somebody, and medications properly understood are really a way to help [00:07:00] somebody do that, but they're not the end of the treatment itself. The end of the treatment itself is for somebody to say, "What are the stories that constitute you and your world?
How can we help you live those stories out better and more fully going forward even after an illness," right? And so sometimes I'll meet students and residents on our service, and they'll say something to me like, the notes are done," or- Mm-hmm ... "I've put in all my orders, and therefore I'm done for the day."
And on the one hand I understand, because that's what they've been asked for by the system to think of their job as, but I'm also deeply saddened because they're not saying that I've got this person going in a direction towards health and towards a restoration of their story. Mm-hmm. They're saying, "I've done this kind of biomechanical chores."
And those biomechanical chores are important. They should be well done, but as Warren says, they're not the art of this work, and they're not the fullness of this craft. The fullness of this craft is a story. So when putting together Prescribing Together, [00:08:00] partly it was born out of Warren and I's shared commitments to what psychiatry is and could be.
Mm-hmm. Partly it's born out of our friendship. Partly it's born out of us wanting to model the ways that we look at the received wisdom of other people. So each chapter in the book, yes, we wrote them, but they're also a deep engagement with somebody who has some wisdom in a particular area. Mm-hmm. So as you mentioned, there are chapters around common diagnoses, and in each of those, we reached out to somebody who...
An expert in the field and had them help us tell their own sense of how they do this work. So we're grateful for everybody, who takes a chance and reads the book and learns about this new way of thinking about psychiatric care. Absolutely. so I wanna go to some of the specific examples because I think this will really illustrate for the audience sort of what you've done.
so I'm thinking about the chapter on, I don't know whether you've labeled it specifically as schizophrenia or, Yeah, schizophrenia and other psychotic disorders. [00:09:00] So a personal vignette first, which is about 36 hours ago I was sitting in my living room watching an episode of a Star Wars series with my son, and, I started, I thought perhaps having some auditory hallucinations.
Could not pinpoint what I was hearing or where I was hearing it from. Over the next 36 hours, it has turned out that I and my wife were both hearing birds in our attic. But this is really disconcerting, and I'm thinking about the reactions that I had, that she had to hearing those noises, right? They have different emotional valences for us, and the reaction that my son had to seeing me sitting in my chair going...
And I couldn't even formulate a sentence to explain to him what was going on, so he really thought I was hearing internal voices and didn't know what to think. you take the approach in this chapter of rather than, as you said, rather than seeing a symptom and [00:10:00] looking for a way to control it, actually engaging with there are these auditory or visual or other hallucinations that somebody's having or delusions that someone's having and engaging with the meaning of those and engaging with what the emotional response to those is.
Because for some of my patients who, have been diagnosed with schizophrenia, their hallucinations don't bother them that much. they have casual conversations with the auditory hallucinatory voices that they have, and it doesn't seem to be particularly distressing to them.
For others, they're terrifying. so let's talk a little bit about that approach, Specific to these disorders. I have some other thoughts as well, but you can start there. Yeah. In the chapter th- where we engage psychosis and schizophrenia, we interviewed a psychiatrist in the UK, Mohammed Rashed, who, practices in the NHS and teaches at King's College London, and he's also trained as a philosopher, and he writes philosophically [00:11:00] about the Mad Pride and Mad Identity Movements, which are- Mm-hmm
here in the US, but especially, much more present in the UK. And the Mad Pride movement, just like, LGBT pride or any other kind of pride movement is a way to reclaim what's been stigmatized and- Mm-hmm ... to find kind of group meaning and identity and advocacy within that. So, Mad Pride, organizations are ones that would say, like, we've been diagnosed with some form of madness."
We obviously trying to reclaim a term that's been stigmatized and to make it a term of group identity, and we're now turning that back on the medical system to say that, madness is just another way of being human, and that our rights need to be understood and respected. And, Dr. Rashed, listening to his own patients and also, researching these movements in the UK, in some ways gestures back to a time in psychiatric history that frankly none of us would want to return to, which is an era before antipsychotics existed, and he also would not say that we should be in a time when, schizophrenia, can't be treated [00:12:00] with antipsychotics.
And yet he says that in some ways we've swung too far in our medical world. We went from the early 20th century, there was a tradition within psychotherapy of trying to understand the meaning of psychotic experiences, of trying to build relationships with patients, of understanding what they were longing for and hoping for as a way of helping them to live with their experiences and to make sense of them.
When chlorpromazine was first introduced in the 1950s and then subsequently, th- the pendulum has swung where we see psychotic experience as primarily a brain condition that needs to be medicated away, and people often end up on very high doses of antipsychotics for a long period of time to try to keep their psychotic experience at bay.
and to the extent that psychiatrists try to build alliance with patients with schizophrenia, it's to encourage them to take their medication. and we see that there's a need actually to think in a broader way. maybe in some cases, voices aren't necessarily getting in someone's way. maybe, our colleague [00:13:00] John Swinton writes about, people he's spoken with in the UK who say, "When my psychiatrist told me that I needed to take medication for my voices, I was worried that I would be lonely because, um, my voices were in some ways Those that I knew around me.
So how do we recognize that, that voices and other psychotic experiences can be negative in someone's life and we'd want them to go away? They could also in some ways be neutral or positive. there's a Hearing Voices Network where people talk about voice hearing as a way of being human. there's a lot more people who hear voices in our culture than are diagnosed with schizophrenia or assigned medication.
So how do we think about the kind of experiences that people are having, meeting them there, thinking pragmatically with them about what it means for them to pursue purposes and goals in their lives, and to start there rather than to assume that any psychotic experience is immediately a sign of a psychotic disorder that needs to be treated with antipsychotic medication?
Jonathan, if I may? Sure. You began with this story of this experience of you and your [00:14:00] wife watching a television show and believing that you'd heard something that you couldn't see. This kind of illusion or perception is something that all of us have, right? One of my first cassette I ever owned was Paul Simon's Graceland, and there's a moment in there where I thought it yelled out my name.
And I'd always run downstairs and ask my mom why she called my name and she said, "I didn't, but now you can help me empty the dishwasher." There's a chore that you had. So I've always disliked Paul Simon's Graceland 'cause it always gave me chores. All of us have perceptions and illusions of reality that don't line up with it, right?
And so the question even in that same scenario is for you to do what you did, which is to ask, "What's the meaning of this sound I'm hearing?" Can I develop evidence for and against it? And importantly, you were able to say that you were able to do that with your wife and your child, and ultimately come to some sense of a shared sense of meaning about that.
And part of what a model [00:15:00] of only prescribe or dispensing medications to people who hear voices does is it robs them of the chance to figure out that sense of meaning- ... in relationship to other people. Because the only meaning that it offers is that they are ill, disabled, something pathological.
Mm-hmm. So part of what we did in the chapter, learning from our colleague in Britain, was to provide some questions that people could ask their patients. Not just, "Do you hear voices?" but, "What does it mean for you that you hear voices?" "Do you want the voices to go away?" Not everyone does, right?
Mm-hmm. And so that, part of what we're trying to do is help people have a sense of agency. Part of what we're trying to do is, is to do what you and your wife and family were able to do, which is to kind of engage these experiences with other people and come to a shared understanding of their meaning- Yeah
while also making sure that people receive evidence-based medical treatments. Right. So- The [00:16:00] referential meaning and significance that, one of the ones that you mentioned that I thought was wonderful, because this speaks to experience that I have. Who is trying to harm you for somebody who may be having a paranoid delusion or hallucination where they feel that they're in danger in some way?
What leads you to think this? Why might they want to harm you? And then how does it feel to believe that others are trying to harm you? I think that I take care of a population that's mostly immigrants and refugees, many of whom have, war trauma, have been through ethnic cleansing experiences and various other really horrible experiences.
Also a number of natural and somewhat man-made disasters like widespread wildfires in their refugee camp that burned down, you know, thousands of people's homes . And I hear descriptions of being attacked by wild animals in the middle of the night, people coming after them with knives while they're dreaming, things that sort of bridge the diagnostic gap between a psychotic disorder and post-traumatic stress disorder.
So this will be a way of [00:17:00] leading into that. and for me it's been really important to try and find out what experiences that maybe the broader community would agree were of this world led to the experience that they're having now in their inner world. and sometimes it's really difficult to get at that because, for many of these cultures it's very stigmatized to even talk about those experiences.
I had one patient where I realized that approach had gone too far because she started talking about how I was being chased by a wild animal, and I fell down in the jungle. And I left that aside, and then it came up again, and her daughter was there, and her daughter, who's now a nurse practitioner, she said, "No, that actually happened."
She was being chased through the jungle by a tiger and fell into a pit and hit herself on the head, and she was unable to, you know, really communicate with people for about a month because she had this terrible head injury, and that happened when she was 18, and she's had trouble ever since.
So I [00:18:00] had over-psychologized something that was actually not just a referential delusion, but in fact a, a real memory, or at least a memory that she had been reconstructing from what people told her I think your point about the overlap between traumatic experience and psychosis is really important.
I work in the VA system, and I have a patient, for example, who came to me maybe five to 10 years ago, having been diagnosed with schizophrenia since the late 1970s, and having spent most of that time on fairly high doses of first generation antipsychotics that really left him quite blunted.
Mm-hmm. And when I began to understand his experience, he had traumatic experience before his service in the Vietnam War. He also had some very specific traumatic experiences in Vietnam, mostly connected to racial hazing. And, he came back from Vietnam, angry and disillusioned and was using some substances, and he [00:19:00] was diagnosed with schizophrenia in the late 1970s when the diagnosis of post-traumatic stress disorder didn't exist because it was introduced in 1980 in the DSM-III.
And we know this from a variety of work that, that veterans, including especially Black male veterans, were sometimes diagnosed with psychotic disorders when they were paranoid, because they thought others were out to harm them, or they were angry, or they were- Mm-hmm ... infringing on social norms.
they were hearing voices, and so they were diagnosed with psychotic experiences. And it became clear to me that his life didn't follow the natural course of schizophrenia. It did follow the natural course of post-traumatic stress disorder. Mm-hmm. But by the time I met him, he'd been highly medicated with antipsychotics for approaching 30 years.
And he lost a lot of his adulthood, frankly, to that. And I think the need to really think about diagnosis carefully, not just to receive diagnoses, but, like, how do we make sense of people's experience is really important. Yeah. So it's not just the lived [00:20:00] experience of the person through their illness to the point where you meet them, but also thinking ahead to what their lived experience is gonna be like if you apply the wrong label.
Yeah. That's very good. Yeah. one of the things I'm privileged to do is to teach the basic sciences to first-year med students, and it's very hard for people because it's the only class where the students come in thinking that they know what the terms mean. In the rest of the med school classes, they're learning a new language.
But the languages of trauma, depression, even being on the spectrum, OCD, all of these have escaped the bounds of psychiatry and have entered popular culture. Mm-hmm. And it's a route where students then, often think that these diseases apply to themselves because many of them have experienced mental illness in one ways or another.
One of the big challenges that I've found for them is recognizing that these symptoms cross boundaries, and that the existence of a symptom doesn't necessarily mean that you have to treat it, right? [00:21:00] One of the big shifts we're trying to get them to see is that the existence of a symptom is an invitation to continue the story and to ask more follow-up questions about what it means, and this is an evidence-based approach.
We know that psychosis, for example, occurs in lots of other conditions besides schizophrenia. We can induce psychosis with sufficient amounts of psychological stress, of physiological stress, and of substances. We know that it's gonna commonly occur in other conditions. So
Just because someone has psychosis doesn't mean they have schizophrenia. What I try to tell med students all the time is that all diagnoses are provisional formula designed for clinical out- action. And what I mean by that is, is that we name something so we can do something about it.
I have a series of jokes I tell med students, and one of them is that we don't commonly measure philtrum size. We could, of course, and it would be reliable and valid to measure philtrum size, but we don't because there's no clinical action associated with [00:22:00] it. If you have a patient with a philtrum size two millimeters larger than average, we're not gonna do anything about it.
That's a normal variation. So we ought to comment about things only 'cause we're gonna do something about it, and that's important because we don't wanna label people. That's not the goal. But we want to be precise when we can because we want to figure out what's the right clinical action. And while there is some overlap, for example, with PTSD and schizophrenia, for the most part, the treatments are actually pretty darn different.
And the outcomes that we think are there and as Warren pointed out, this is a person who, at least in this story that he's telling, right, has really been disfigured by getting that diagnosis wrong. And the kind of future and the horizon for this person, where the story goes and how it ends has really been altered by making a bad diagnosis.
And so it's our responsibility to be careful and thoughtful and think about these symptoms across diagnostic categories- Mm-hmm ... in the context of a person's life . Yeah, I really [00:23:00] appreciate that thought. What I'm gonna play a reverse card like you do in Uno for a second and- Okay
and have Abraham take this next question first. You had said something in talking about the folks that are here having auditory hallucinations, and the one patient that you mentioned who worried that he would be lonely if his voices went away. it kind of reminded me of many of my patients who have major depressive disorder who are hesitant about going on an SSRI or other antidepressant because they've heard that people stop feeling sad but that they feel kind of apathetic or flat.
and that, the feeling of depression is preferable to them to not feeling anything at all Yeah. I guess I would say that SSRIs are one of the most commonly prescribed medications in the United States, and it's one of the been one of the most fascinating cultural and medical phenomenons, where they're really not necessarily more effective than an earlier generation of treatments for depression, but they're much easier to prescribe and [00:24:00] have much less risk of serious adverse events, and frankly, they've been marketed differently.
So their use has been widely done outside of psychiatry. Mm. Most SSRIs are not prescribed by psychiatrists in the United States or even by other kinds of mental health clinicians. So one of the things that we try to teach med students today, and that has been a source of hope for me in the last 10 years, is that there's been a growing sense that we should think about prescribing connections at the same time that we prescribe medications.
and when you talk about that question of social connections, so I've started to include, even when I'm teaching the basic sciences to med students, a list of social connections you can prescribe for your patient, right? Because it is true, people who are depressed often feel this loss of social connection, and in some ways, the medications can either help or harm that.
Everybody's experience is different. So it's part of your job to say, "Look, if you believe that human beings are dependent animals on [00:25:00] with each other and that we're all interconnected," you've gotta ask somebody, "Who else is in your world? Who else used to be in your world? Who else would you like to be in your world moving forward?
And how can we help you reactivate that web or set of connections for you?" So yeah, some people don't like the way SSRIs make them feel. The big thing I'd say is you need to have a clinician that you can talk to and be open about that, but you should also have a clinician who at the same time is gonna prescribe social connections to you at the same time that they're prescribing a psych med.
Okay. And this is something that I know happens even more often outside the US, that in the UK there is a real strong movement of social prescribing, of saying, you know, "Engage in this activity," or, go to this group," or something of that sort, so, I feel like that fits well. You can do it in the United States too, right?
There's nothing stopping it. There are some social forces and structural forces in American medicine, but, it's [00:26:00] actually... One of the things that I learned this from years ago was that there was a patient that was- Mm-hmm ... referred to for psychotherapy, and saw her once a week for three years. But she came to me initially as a med visit, and she'd come off the consult service after a suicide attempt in our residency, and she was seen by the consult psychiatrist, and he had written for her, Gary Gallo, Warren, you probably know him.
Gary Gallo had taken out a prescription pad and wrote in, "Take a walk every day," and signed it. And she talked for years about that in therapy. She talked about how much it meant to her that he'd written this prescription. She kept it on her fridge, and she'd say, "Dr.- Mm
Gary wants me to take a walk today." And it's a really small thing, but it worked for her. There's intriguing evidence in the literature that this works in lots of ways. There's these cool studies that show that patients who are hospitalized after a suicide attempt, that a single postcard or a text checking in on them in the first 30 days post-discharges- reduces mortality. So these simple [00:27:00] tools for social prescribing really do have a good evidence base. They're very inexpensive, and they make sense. it's a nice thing for all of us when somebody we care about checks in and says, "Hey, how are you doing today?" Right? and so those are the kinds of things people can think about.
So I would say your original question was about these kinds of ways which sometimes people feel flattened or dulled by their meds. One is you should have a doctor that you can talk to about that stuff, and two is you should think about having some ameliorating and activating forces through social connection .
Mm-hmm. I would just echo that, and I think that an- serotonin specific reuptake inhibitors and medications like that are neither as big of a problem as they're sometimes made out to be, especially in our current, scientific political climate. nor are they as much of a solution as their most ardent champions from pharma advertising to overzealous clinicians would make them out to be.
Often They can [00:28:00] make people feel a little blunted. They can also help people to have, much less intense experiences of depression and anxiety. they can cause some other side effects but they're at best like one part of an overall plan. I think the bigger danger with SSRIs for depression and for anxiety is not their specific physiological effects, but that they can get people locked into a biological or neurobiological imaginary for themselves so that you take a medication, the medication works or it doesn't.
If the medication works, it proves that the problem was biological to begin with. If it doesn't work, it proves that you need a different medication, and that can over-individualize the experiences of depression and anxiety as if they're only things that are happening inside of us. and it can lead us to, look to biology and not to the outside of us, to the world in which we live.
So a lot of people are experiencing anxiety and depression, not because there's any one particular thing that's broken in their brain, but because they live in a world that is not meeting their basic needs for [00:29:00] connection- Mm-hmm ... and for relationship and for meaning and for purpose and vocation and safety.
And in a world where those needs aren't met, we're gonna feel anxious, and cumulative over time, we may feel demoralized or depressed and, medications may play a role in helping people to live with that, but they're certainly not the only solution. So thinking in a more holistic way, as Abraham's describing, it's just part of good practice, and I think good clinicians- Mm-hmm
already do that and know that, but it's important to say that. Yeah. and I hear you moving back into the world of story. I'm looking at your conclusion right now, and, one of the things that you do is you talk about, the way that certain things become characters in the story that the patient tells.
And certainly what you were just describing is the setting of the story, all of the different societal forces that they're encountering and the external experiences that they're having, and that the medication and the clinician, in addition to the patients themselves, become characters in the story that are moving through that world.
That's right. It's like [00:30:00] medications are characters in a story. I think understanding people not as bearers of symptoms, but as inhabitants of stories is essential to what we're trying to do. Mm-hmm. And what makes psychiatric practice so rewarding and so challenging is not the identification of symptoms.
That can be challenging. It's not nothing. But it's learning how wisely to, be part of collaborating with somebody and understanding the stories that have formed them, and in understanding the story that they inhabit, and diagnosis is a part of that story. That's a lifetime of work, and I think Abraham and I are both, have both been doing this for a while, but we have a lot to learn and I think it's always an adventure.
You mean you're not done learning? I'm shocked. Hardly. there's a lot of books behind Warren's head. Yeah. and one thing that I'm sure of is that neither one of us is gonna die having read all the books we feel like we should, right? That's definitely- Or wrestled with all the ideas that we should.
Yep. one gift of this life, is that people surprise you, right? that every time you meet somebody, [00:31:00] it's like you get to travel a little bit. You get to encounter something new and interesting, and that's part of the strategy that we hope people adopt- is a kind of humility towards, a patient, but also a sense of curiosity about them, right? I think one of the things that makes this work possible and sustainable is a sense of wonder about other people. How are they in the world, right? I've lived only my own limited life. I'm happy with it, I'm grateful for it, but it's my way of living in the world and there's lots of other interesting ways of living in the world and I'm really grateful for the chance to hear somebody's story.
It's honestly more interesting to me right now than, as Warren said, it's pretty easy to figure out which SSRI to pick. ... I've got that down. I have a sort of set of algorithms and ways to think about that. That's not the part that's interesting about being a psychiatrist.
The part that's interesting is meeting somebody and trying to figure out how they stick themselves in the world. Mm-hmm. I think especially maybe for the primary care clinician, one of the most difficult areas to find yourself in is, or at least It might [00:32:00] not be the most difficult, but it often is perceived as this and there's a certain resistance, I think, to working with patients who carry this label, is, what is generally considered the Axis II disorders the personality disorders, which I know is a term that a lot of us are uncomfortable with anyway, but particularly borderline personality disorder, who seem to me to be the patients who are most often to be labeled as difficult, to be, people that clinicians who are in a rush want to avoid, that, kind of get our armor on.
This is, thinking back to my previous interview with, Brian Miller, who's a therapist talking about, you know, ungloving instead of armoring up, that these seem to be the people we armor up for. you have some very interesting thoughts about how to approach this differently, and building alliances in ways that I think a lot of us don't succeed in doing.
Yeah, I would just echo what Abraham said that a good diagnosis is one that leads to a helpful pathway forward, and a bad diagnosis is one that doesn't lead to a helpful pathway forward [00:33:00] even if it meets the checkboxes of the DSM. and I think in that case, thinking about borderline personality disorder specifically it's kind of unfair that it's got the stigma associated with it that it does.
Mm-hmm. In part, that's a relic of the history of psychiatry because back in the 1980s, early 1990s when Judith Herman was just writing her book, Trauma and Recovery, and actually promoted a new diagnosis of complex PTSD, This is before Abraham's and my time in psychiatry, but, psychotherapy for people with borderline personality disorder was often, long-term.
It was psychoanalytically focused- Mm-hmm ... and there began this literature that, people with borderline personality disorder just don't get better in psychoanalytic psychotherapy. Now, I don't think that's entirely true. It's certainly not true with some of the, newer psychoanalytic therapies that are specific to borderline personality like mentalization-based therapy, for example.
Mm-hmm. But it was perceived as true at the time, and so there was this sense that, that borderline personality was something that was difficult to treat. [00:34:00] But frankly, that's different now.the, DBT is the flagship, but also many other forms of therapy- Mm-hmm ... have come along, and, people can, just experience dramatic improvement from the core experiences of borderline personality disorder, and it has to do with establishing, again, a trusting relationship.
It has to do with the right kind of therapeutic boundaries but also the right kind of connection and attachment to a therapist. Has to do with encouraging people to, take chances but also to know how to regulate their own behavior and their own emotions and how to tolerate distressing emotions and yet move forward toward what's good.
All these kind of core skills that DBT- Mm-hmm ... teaches, and people can do dramatically better. And so in that case, much better for someone to be diagnosed with borderline personality that can lead to a helpful therapeutic pathway forward than to have- Mm-hmm ... the same experiences and be diagnosed with something else for example, bipolar II disorder- Mm-hmm
and that tends to lead to, an idea that this must be medication, ... focused in the treatment and end up on five or six or [00:35:00] seven different mental health medications and not actually- ... receive the treatment that is life-giving and healing. So I think, again, like, being open and pragmatic with respect to diagnosis.
Mm-hmm. and in, you know, in the book, We, interview Sarah Feinberg, who's a really talented, clinician in terms of thinking about questions of building relationships with people with bipolar disorder, and she's actually an advocate for thinking about de-prescribing. Not because medications are always wrong, but because we have to think about, like, how do we apply the treatments that we're offering and make sure that they're actually helping people.
Mm-hmm. And making sure people get what they need in therapy. Yeah. and I like that you're describing, The use of DBT and the engagement with people with borderline personality disorder as a way of leaning in and establishing relationships, and, that the relationship is the therapeutic part.
That being able- Yeah ... to continue on with this person and engage with them is what actually gets them better. I find that that relationship part is something you can establish even in the [00:36:00] diagnosis. Mm-hmm. I don't know about Warren, but for me, most of my psychiatric trainees are very interested in reducing stigma around mental health, right?
It's a big factor for this generation. It's been really wonderful to see. When we went to med school, there was still much more internalized stigma around it. Now we've got lots of people wanting to go into psychiatry as a field, and they're almost universally interested in reducing stigma around mental illness.
But then I'll ask my trainees who have a patient with borderline personality disorder, "Have you told the patient that they have borderline personality disorder?" And they'll often say no. And they'll say, "I don't know how to do that. I'm afraid to say that to them." And I'm like, "That's stigma right there," right?
We, you, if you can't tell somebody you have the diagnosis. And then I volunteer to go show them how to tell somebody. And I have found that it's helpful- Mm-hmm ... to say that to own it first, that we all have certain patterns of the way we perceive ourselves and others, ways we relate to ourselves and other people in the world, and that if we look back on our life, all of [00:37:00] us wind up kind of making the same mistakes and having the same kinds of successes.
I've known Warren long enough that I've made some of those same mistakes in front of him, right that we've been- Mm-hmm ... friends long enough that he kind of knows I, who I am and what I'm gonna be. And then we talk about how for some of us, those get us in trouble in certain ways, and that's all of us, including me, and how they usually come out when somebody has to address some change that they didn't invite.
And I talk about how all of us don't really want change. We're all designed for entropy, and so we, we activate these defenses in response to that. And if you understand that you are the kind of person who resists change, and you are the kind of person who activates certain kinds of defenses in response to change, right?
Certain kind of moments when you show up less well than you normally would like to. That's really just what the borderline personality disorder is. They're human, just like the rest of us, having an extremely human moment, and it [00:38:00] can be extreme. We talked earlier about how psychosis occurs across boundaries.
It's called borderline, not because it's like bipolar, which people often think, but because in a psychoanalytic model, it's on the borderline between a neurotic response to life's changes and a psychotic response to life's changes. And that's why, because of that swinging back and forth between those neurotic and psychotic poles, that patients with borderline personality disorder, in these moments of extreme emotion, a clinician reaches for what seems like the best way to get them back in control, which is a medication, and then people often wind up on lots of different medications that there isn't really a great evidence base for.
They're not specific to the treatment. And then it becomes hard to know, once somebody's returned to a place of emotional stability, people wind up with this logical fallacy, which they'll say, "Well, you're on these four medications, and you're doing okay, so we'll probably continue the [00:39:00] medications."
But it may be that threat of change is actually, in responding to that threat of change is no longer active, and they've done the work of responding to it. So now it's time to think about de-prescribe these medications. And that's why we interviewed Dr. Feinberg about this question of
If you're going to do the act of prescribing, one, it's gotta be done in the context of trust. Mm-hmm. But two, you should also think about when you're gonna stop a medication, right? Yeah. And so if I may go back to one... a little bit to the previous topic, part of why I don't like to call drugs that are SSRIs antidepressants is because I think that even the words we use are important, and it's not that these drugs take away depression.
It's not like an antibiotic, right? This is a medication that... An SSRI is at least a biological way to think about it, which is, to me, a l- at least it's imperfect, as Warren mentioned, but it's a better way than saying it's an antidepressant, where it just takes it [00:40:00] away. And so similarly, when you're giving people medications for borderline personality disorder, the first thing that I try to do is remember that they're having an extremely human moment, that I have extremely human moments and I think about what they want is some version of what we all want in an extremely human moment, which is somebody to be thoughtfully human back with them.
Yeah. what my, reaction to what you had said a second ago, Abraham, is that, the fear of giving somebody that diagnosis very much mirrors the fear that we have in the internal medicine world of saying that we're even considering a cancer diagnosis, or that we're worried someone might have HIV,
or some of the degenerative neurological disorders. Like, those are things where people really have to be trained to raise the possibility of that diagnosis, say it, because they're so afraid how somebody's gonna react. So hearing you say, yeah, people don't easily give the diagnosis to somebody with borderline personality disorder immediately tells me that [00:41:00] they're somehow fearing a reaction that they won't know how to handle.
I would say in psychiatry it's, there's a grace to offering a framework by which people can understand themselves in a helpful, new way. And that could include a diagnosis that, maybe seem hard to give. I had a patient a few years ago who was, first of all, a man, so it didn't fit the stereotypes that a lot of clinicians have about borderline personality disorder.
He'd been diagnosed... He had a strong trauma history. He'd been diagnosed with varieties of bipolar disorder and depression, was on a bunch of medications that w- didn't seem to be helping. After listening to his story, I said, "Well, here's a particular pattern of experience that some people- who've been through similar kinds of experiences to you feel," and I described in lay terms what borderline personality disorder, you know, feels like from the inside, and he really resonated with it. And he said, "What did you say that was?" And I said, "Well, here's the diagnosis. You can look it up after you leave.
You m- may find various things written about it but, I want you to consider whether this would be help- a helpful way to describe your experience." And he left my [00:42:00] office, and then he called me two days later and said, "Dr. Kinghorn, like I've been reading about this, and it names exactly what I've been experiencing for years."
Mm-hmm. And he was really actually excited to have that way and then that was a way to get him into effective treatments. And I just think, there's a grace to offering- Mm-hmm ... frameworks that are helpful. So A good diagnosis leads to a helpful pathway forward.
For sure. So we're getting close on time. I know we have a hard stop in a few minutes for, for Abraham. So I wanted to maybe have a one last question that's a little bit more philosophical leading to the ultimate question. so I've been recently reading Viktor Frankl's The Doctor and the Soul, and on the one hand, it sounds like you're very much describing the psychiatric approach that he talks about, which is that his idea of psychotherapy is getting at meaning rather than just at symptoms, that it's not about fixing the specific complaints but really about integrating a story.
but I also read that book, and I [00:43:00] think this language sounds archaic. I don't hear my colleagues in the behavioral health professions talking this way and talking about things in these terms, and I wonder whether this was a moment in the '40s, '50s, '60s that we've moved away from. So enlighten me.
I don't see Warren volunteering, so maybe I'll wade in for the reasons. Victor Frankl was a remarkable writer, incredibly successful. His books are still in print and still widely read. and I do think that we share with him some of those commitments. I don't have a sense that he's being read widely within the field.
He's not being referenced and engaged in psychiatric journals in a significant way. but I don't think that's because people don't respect him. I think it's partly just because the approach that he takes is rooted in psychoanalytic, and uses a language that people don't use quite in the same way anymore.
They tend to use... A lot of the [00:44:00] energy is around third wave therapies, and some of the biological language. So I think that's probably the answer I'd give. But I think it's still a very helpful book for people to read, when they're thinking about this kind of work. Great. I'd say to clinicians who are inclined to read Frankl or who think in more meaning-oriented existential terms, try it out with your patients and colleagues.
You know, ask patients, like, what gives meaning to their life and why they want to keep living and, what gives them hope and joy, and see what they say. And ask colleagues the same thing. And I think there's an appetite and frankly a longing for those questions to be able to be surfaced, but it just takes somebody to break the ice and to use the language and to ask.
Excellent segue. So in breaking the ice, I recognize that a lot of the psychiatrists that are listening or that are out there in the world may be seeing patients in these very bite-sized packets of 15 minutes, but far more frequently than I as a primary care doctor might have the opportunity [00:45:00] to see them.
They may be seeing them on alternating weeks or even weekly, but not for a very long time. Where do you suggest breaking the ice, recognizing that a conversation like what you're describing might take, you know, eight or 10 or 12 visits to actually reach an agreement on something? you mentioned that I like stories- Mm
and there's a famous storytelling device called Chekhov's Gun- Mm ... which is that there's this short story Chekhov writes, and in the opening paragraph there's a gun on the wall, and nothing happens with it till the very end of the story. But the point is that you know that it's there the entire time.
And I guess I would say you can break the ice even in the first encounter, right? in the old psychoanalytic tradition, people would often say that what people said in their first response was often what they then would spend years working out, right? That everything was in some level there in the first response.
So part of what we want people to see is that when you're prescribing a medication, you're also [00:46:00] prescribing one kind of therapeutic alliance or the other, and you can turn that from one that is a dispenser model towards one where you're really accompanying the patient in the different models that we laid out in this book.
Mm. But you're breaking the ice the whole time. The question is how you're breaking the ice, and you can break the ice with an encounter with somebody from the very first time where you're putting them in what Warren calls this kind of neurobiological imaginary, where what's going on is you have a chemical imbalance and you need to take this medication.
You can start with that kind of story, or you can start with the kind of story where you're saying, "We want to think about the meaning of these symptoms in your life and where this story goes." But you're breaking the ice the whole time is I guess what I would say. I like that. And I would echo that, and I would say that building an alliance with patients starts from the very first minute- Mm
of the first encounter. And it's not instrumental to the work. We don't build alliances so that then we can prescribe [00:47:00] medication. But it is the work, and frankly, it is a lot of where the healing comes from in any clinical encounter. I think that's a great place to end. thank you both so much for joining me.
I think even though I'm not a psychiatrist, I certainly have, from reading the book and even more so after today have some tools in my toolkit that I didn't have before to, to engage with some of the behavioral health challenges that my own patients have and are coming to me about. because as you know, you people are hard to find.
And, I hope that it's been helpful for everybody listening as well. Thank you so much. Thanks, Jonathan. Yeah, Jonathan, we thank you for the opportunity. We thank all your listeners for taking care of people with mental illness, and we thank anybody who reads the book and learns from these people.
We had such a privilege interviewing all of these great psychiatrists and psychologists, and providing some tips and tricks from them. So thank you. Welcome.
[00:00:00] When I was listening to Warren and Abraham talk, I was really struck by how much joy and appreciation they have in their work. But beyond joy and appreciation, I noticed something else, something that in Hebrew we'd probably call yirah. Yirah means... Well, it's not really clear what it means. It's a tricky word.
I think it comes closest to what the Polish-born American rabbi, Abraham Joshua Heschel, used to refer to as radical amazement, standing in awe of something. Heschel was usually talking about a sunset or the enormity of the universe when he meant radical amazement. But you can be radically amazed by something about a person as well.
And I get the impression that Warren and Abraham both have that feeling of radical amazement for the experiences that their patients go through. It's one surefire way to appreciate the humanity, the dignity, the struggle that somebody goes through when they're grappling with really severe mental illness, as many of their patients are.
Mine, too [00:01:00] Having yirah for something means that we're not automatically trying to get rid of it. How could you get rid of something that's so radically amazing? Better we should try to understand it, even if, as Heschel often says, it is ineffable. Can't understand it There's another aspect to it that arises out of having that degree of yirah for it.
There's a story that I tell all the time to remind people that we shouldn't glorify other people's suffering or say, "You must be suffering for a reason." Something that the Talmud calls yisorim shel ahavah, afflictions of love. The famous story in the Talmud in Tractate Berakhot talks about a cadre of four rabbis who lift each other up from their suffering The commentator Rachamim Weiss, writing in the early 21st century, talks about them as a conspiracy against suffering or an underground against suffering, and they have a code [00:02:00] word: "Is your suffering welcome to you?
Neither it nor its reward." But sometimes it's not really suffering, or perhaps it is welcome. Just as we shouldn't judge that somebody is suffering sufferings of love that they should bear with equanimity and even joy when they're not interested in bearing those with joy, we also shouldn't presume that somebody who's suffering from delusions, having various other types of behaviors that we would consider mentally ill, that person is necessarily engaged in suffering.
Perhaps it does have meaning to them. Perhaps it is their way of coping with a universe that seems completely out of whack Maybe their suffering is welcome to them. Whatever the case, I think it's definitely worth adopting that attitude of yirah, of radical amazement towards what our patients are going through.
Even if they then say, "Please, [00:03:00] help me to end what I'm going through and return to the world that everybody else inhabits," that's okay. Beginning from that point of humility, that point of standing in awe of what our patients are going through, is really the jumping off point for any medicine, but especially for mental health.
I hope this episode inspired you as much as it did me, and I hope that you can all go forth with a new appreciation for the strength and courage that the people you care for who are grappling with mental health struggles are exhibiting every day in every way. Have a good night
[00:00:00] One quick additional footnote to this episode. The story that I told at the beginning of the episode, the Turkey Prince, that was a story, as I said, from Rabbi Nachman of Breslov, an 18th century Hasidic rabbi who was one of the great masters of that movement. Much of Rabbi Nachman's wisdom can be found in his books and on the website breslov.org, B-R-E-S-L-O-V.org And this version of the story is from that website.
Wanted to give credit where credit is due