A comment I received suggested that I explain the differences between the traditional approach to medical treatment and what I am proposing through a resilience approach to psychiatry.

In the traditional model, a person comes to their physician with a problem. Through questions and diagnostic tools used to identify symptoms, signs and other markers for the illness, the physician makes a diagnosis based on an understanding of the reasons why such a problem would exist. Based on this diagnosis, the physician prescribes a medication with the goal of treating or palliating the problem. At some point in the future, the physician would reassess the patient to see if his or her symptoms had abated, and if not, revise their diagnosis and treatment until cure or adequate palliation.

In resilience health, there are two possible avenues to enter the system. In the first path, a person would approach the doctor similar to the way they might above, with a problem. In this pathway, the doctor would assess, diagnose and treat the problem in a similar way as the physician above might, but would also assess unique individual capacities, strengths and vulnerabilities and with the persons' participation, act as a guide to promote what the person is already doing well and make suggestions about modifying risk factors. This is actually what should be going on in most doctors appointments, but due to time constraints, the strength/vulnerability part is often boiled down to an assessment of problematic behaviors (drinking, drugs, smoking, dietary no-no's, sedentary habits, risky sexual behavior, sun block, seat belt use and helmet use).

The second entry point would be more of a yearly check-up/tune-up. I want to save this approach for later so I can spend a whole post outlining what this might look like.

I think the best way to demonstrate differences would be to describe two different kinds of psychiatric visits I've performed.

Traditional/typical approach:

I saw a middle aged female patient at a community clinic last week who had been given a diagnosis of bipolar disorder. After exchanging smiles and hand shakes, I asked what I could do to help. She said that she was there for a prescription and that her life, though stressful at times, was going well. I asked a little more about that and she offered that she had been having some troubles with her children who were taking advantage of her generosity and hadn't been looking for jobs as they told her they would. I asked her about how this had affected her, and she said that she was sleeping less well, and had been eating less for the past two weeks. I asked her if her mood had changed, or she had any symptoms relating to her bipolar diagnosis and she told me that she had been a little more irritable. Even so, she told me that the medication was keeping her "steady" and that she didn't make any changes to the medication regimen that she had been using for the past four years. I asked her if she wanted to see anyone to talk about her stress. She said she was fine, and that she would be talking to her case manager later in the day. I asked if she had been having any side effects from the medications. She denied any. I assessed for suicidality or homicidality, and she denied both. I wrote her scripts and suggested that we meet again in two months. She smiled, I smiled and she left the office.

Resilience approach:

I saw a younger male patient the other day who had been given a diagnosis of generalized anxiety disorder. I invited him into my office, smiled and shook hands.  I asked him how he was doing. Being new to me, he provided a short explanation of the course of his illness, including where he thought things began and where he was right now regarding his symptoms. In his narrative, he told me about his love of music and performance, and how his anxiety had impacted his ability to play instruments, making him sick before shows, with horrible nausea, sweaty palms, dry mouth and a feeling like his stomach was on fire. I heard that he had suffered a great deal due to his condition, but that he was making the best of his situation. He did this by making furtive half statements like "I think things are more under control now," or "I've been working hard on that and its been a little better." I asked him what he was doing to get things "under control" and he said that, before performing he told himself that his acute anxiety would pass once he got into it (reflection), and that he "pepped" himself up before going on stage saying things like "I can do this! This is going to be fun! I love stuff like this." (reappraisal) He then looked at me and said, "no one can tell I'm scared out of my mind... I guess my natural vibrato hides the shakiness of my voice ok." (humor). I asked him if he had learned anything else that could help him and he said that his father had used beer, but that he knew better than that.

I smiled at him, and told him how much I admired his strength, and determination to overcome his fears and symptoms. I explained how the body reacts to stress using the "fight-or-flight" system and how his reactions were on the high end of the normal spectrum. I also reflected with him that it seemed as though the repeated activation of his stress system was wearing away at his reserve. I named the skills he had been using to control his anxiety (reflection, reappraisal and humor), explaining how each of them work and suggesting slight modifications that might help. I affirmed that his hope for feeling better was well founded, and that through working together, he could get a handle on how he felt. I shared my thoughts that his anxiety was part of his family's psychiatric history, and that there were better, and safer tools than beer which he could use to overcome it. After answering a few of his questions, I provided him with scripts for medications he was taking and suggested a Beta Blocker for performance anxiety. He explained that the previous doctor he had seen had suggested this too, but he had refused, worried that he would get addicted to them. We spoke about the risks and the benefits, and he was exited that they might help him before an upcoming performance. We shook hands and he said "this was the best doctors appointment I have ever had." I smiled and told him how much I admired his strength.  We planned a meeting in two weeks to see how things were going.


Hope this helps!