Margaret Chisolm, M.D., co-authored the Systematic Psychiatric Evaluation: A Step-by-Step Guide to Applying The Perspectives of Psychiatry geared towards mental health professionals. In From Survive to Thrive: Living Your Best Life with Mental Illness, Chisolm translates the Johns Hopkins Perspectives approach for the lay audience — in particular, for patients and their families — and incorporates a roadmap to take patients with mental illness from surviving to thriving.
Margaret Chisolm MD (Photo credit: Greg Dohler)
Four Perspectives (the Whole Person Framework) for Understanding Mental Distress
• Life Story Perspective — a Frog Reading a Book
Recognizes the importance of events in a person’s life that may be relevant to their current problems
• Dimensional Perspective — a Folded Piece of Paper
Takes into account the cognitive and temperamental aspects of a person in understanding their current mental distress
• Behavior Perspective — a Rat in the Cage
Considers patterns in a person’s behavior that arise from conditioned learning
• Disease Perspective — a Bear with the Broken Arm
Understands mental illness as arising from a broken part or function, often — but not always — originating in the brain
Dean MacKinnon, M.D., illustrates the Johns Hopkins Perspectives as a method of clinical reasoning and walks through the diagnostic formulation using the Perspectives. Watch video
1. What was your metaphorical kick in the rear to put pen to paper and write this book?
I’ve been seeing patients for more than 30 years, and one question new patients always ask is what approach or philosophy I use, e.g., psychoanalysis, biological psychiatry, etc. In response, I always explain the Perspectives approach verbally, but it was frustrating that no book existed that I could hand over to my patients or their family members who wanted to know more. So, I’ve been thinking about writing this book for many years. Kostas Lyketsos, M.D. and I wrote the Systematic Psychiatric Evaluation book for trainees and practitioners about a decade ago, but I also wanted to give my patients a resource, so this book felt like the right next step.
2. Illustrations play a big role in translating key concepts in your book — the four perspectives, the four pathways, and the levels at the airport where perspectives and pathways intersect. What was your process for the illustrations, for the four perspectives, in particular?
I taught a course for psychiatry interns and medical residents on the Four Perspectives and found illustrations useful in clarifying the concepts. The illustrator and I wanted to keep the images accessible to the average reader and also make them a little whimsical. Although mental illness is a serious topic, we wanted the images in this book to be uplifting and more hopeful.
The Frog Reading a Book for the Life Story Perspective is inspired from fairy tales and storytelling. The image is meant to remind us of the importance of the personal narrative in mental illness. The Rat in the Cage for the Behavior Perspective references the research rat and behavioral science. The cage captures how a person finds themselves stuck in certain behavior patterns. The Bear with the Broken Arm is for the Disease Perspective. The broken arm reflects the idea of the broken part or function inherent in this perspective. The illustration for the Dimensional Perspective was the most challenging, as the bell-shaped curve would be well-suited, but it was not an option given its controversies. So, we arrived at the folded piece of paper — origami bird. This represents the way various personality dimensions can — especially if extreme — lead to mental distress.
3. Case studies are the standard mode for consultation among clinicians and for professional education in the health profession. As an educator and a clinician, what was your decision-making process for incorporating your personal experience and your patients’ experience in the book’s case studies?
My two main goals in writing this book were to demystify and to destigmatize psychiatry and psychiatric illness. When I taught this to small groups of internal medicine residents, I used Ernest Hemingway as a case study. Each group got one portion of Hemingway’s history that highlighted one of the four perspectives, and they would then work together to piece together the different pieces of the history into a complete ‘evaluation’ that includes consideration of Hemingway from all four perspectives.
I wanted to have a case history as a thread that I weaved through the entire book. Frankly, I would have needed to do a lot more research on Ernest Hemingway or another well-known figure in the writing of this book. Because I know my story all too well, I decided — instead — to use my personal experience with mental illness as that thread. Not only is it a way to connect the reader to the author; it also helps to destigmatize psychiatric illness, which was one of my main goals in writing the book.
In addition, I wanted to bring specific concepts to life with digestible, relatable case studies of composite patients. I tried to share hopeful stories because what we hear in the media are usually the unsuccessful stories, which does not accurately represent how treatable most psychiatric illnesses are. I also wanted to be truthful and did not shy away from the reality of the serious nature of these illnesses, such as in sharing my brother’s story.
4. Often there is the asymmetrical power between clinician and patient. This book is a great tool to put agency and empowerment back to the patient by providing a common language by which the clinician and patient can work together to gain insight into the whole patient and thereby work towards a comprehensive, personized treatment plan. How do you envision for the patient and clinician to use the book together?
One of the themes of the book is that the patient-clinician relationship should always be a collaboration. As a psychiatrist, I want to work together with the patient from the very beginning. I let them know what to expect from the evaluation, after which — before sharing my ideas — I ask them if they have anything to tell me that I haven’t asked about, or have any questions for me. I then let them know how I’m thinking about their problems, afterwards asking them what they think of my understanding/thoughts. Patients often need support in increasing their sense of agency in their lives, and I want to let them know that they are in the driver’s seat and that we, as clinicians, are here to share our opinions, based on our knowledge and experience.
Another theme of the book that I’d like to emphasize is that psychiatric treatment is not “one size fits all,” which is why we use multiple perspectives and tools to understand and treat the whole person. The self-reflection exercises peppered throughout the book are designed to help patients and their family members understand their mental illness and strengthen the various aspects of their lives — specifically, family, work, education, and community — pathways towards thriving. This, once again, helps support the agency of patients and allows them to be in the driver’s seat.