How to help patients build fulfilling lives even in the face of unremitted illness.

Publication Date: 03/17/2025 

Duration: 15 minutes, 19 seconds 

KELLIE NEWSOME: Today, we look at how to help patients live better lives – with or without recovery from mental illness. Welcome to The Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.  

CHRIS AIKEN: I’m Chris Aiken, the editor-in-chief of the Carlat Report.  

KELLIE NEWSOME: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue. 

CHRIS AIKEN: In 1964, Joanne Greenberg published a book about her experience with mental illness. I Never Promised You a Rose Garden would go on to sell millions of copies and was adapted into a movie, a play, and a hit country song. The title comes from something her psychoanalyst, Frieda Fromm-Reichmann, told her when she was a patient at Chesnutt Lodge:  I never promised you a rose garden. It echoes Freud’s comment that the goal of psychoanalysis is to replace neurotic misery with ordinary unhappiness. And why do we start podcast on flourishing on such a dour note? Because we are about to look at how to help people with mental illness lead more fulfilling lives, and I want to keep this grounded as we go forth. Life is hard. Mental illness is hard. Full recovery isn’t always possible, and part of recovery is learning to ride the ebb and flow of ordinary unhappiness, something we all do but is a little more difficult when the symptoms you are used to seeking medical treatment for – anxiety, depression, insomnia – bear an uncanny resemblance to the symptoms of everyday life. 

KELLIE NEWSOME: Today, we’re going to look at what science has found about flourishing and how we can help our patients use that knowledge to convert some of that ordinary unhappiness into joy, inspiration, and contentment. It is the final coda to our interview series with Margaret Chisolm, who wrote about flourishing in her book From Survive to Thrive: Living Your Best Life with Mental Illness, which won a Nautilus Book Award. In an earlier podcast, Dr. Chisolm described the four Perspectives she uses to assess the problems that patients bring – the medical model, which includes DSM disorders; the dimensional model, which includes personality traits; the behavioral model of habits and addictions; and the life story perspective which looks at the meanings patients make of key life events. She began by clarifying that flourishing is a very different concept, one that looks at possibilities, not problems, one that is focused on the future not the past. 

MARGARET CHISOLM: The thing about the life story perspective is it's retrospective, it's looking backward in time.These pathways are really looking forward in time and thinking about what is somebody's goals. What's going to keep them moving forward, getting a little better each day, in some aspect of their life. The perspectives model is more focused on psychiatric problems, and the flourishing model is more focused on living your life to the fullest potential, regardless of whether that trajectory has changed because of the psychiatric problems or not. Maybe their hallucinations and delusions aren't going to get any better, but the quality of life can still keep improving as they form close social relationships, take care of their physical health, find some meaning and purpose in a job or other activities. I just don'tthink being satisfied with a non-flourishing life, a languishing life, is acceptable for any of our patients. I would not accept that for any of my patients. The example I often give is a patient with addiction who is pregnant, I worked for 10 years at the Center for Addiction and Pregnancy, and I'm able to help her stay off drugs during the pregnancy, but then after the pregnancy, there's positive reinforcers, less motivation externally, and so we need to strengthen these pathways. Like if she's burned bridges with her family members, needs to kind of reconnect with those needs to get work or as a positive reinforcer that would compete with the drug use, continue education, reconnect with the community, whether it's a faith community or connect with a new community like AA or NA. So, all those things are going to be necessary, not only to help maintain recovery but also to be able to go beyond the problems that have constrained her towards this new life and new path forward.  

KELLIE NEWSOME: Let’s pause for a preview of the CME quiz for this episode. Earn CME for each episode through the link in the show notes.  

1. Which of these is one of the four ingredients to flourishing as described by Dr. Chisolm? 

A. Education 

B. Exercise 

C. Health 

D. Optimism 

CHRIS AIKEN: Tell us more about your model of health. 

MARGARET CHISOLM: A lot of my work has been informed by Tyler Vander Wheele’s Model of Flourishing, and he wrote a JAMA paper in 2019 called “Reimagining Health.” Basically, he also is making explicit things that we know implicitly, which is that leading your best life has several domains. The ones that he’s talked about when considering what it means to lead a good life are happiness, life satisfaction, mental and physical health, meaning and purpose, character and virtue, and close social relationships (which philosophers have talked about for a long time considering what it means to lead a good life). He also talks about financial stability or material security. So, you know those are the components which most people would agree to lead a good life. And what Tyler has done is, he’s an epidemiologist who studies these large longitudinal data sets, and his area of expertise is causal inference, so he’s drawn causal links from these data sets between the pathways of flourishing and these domains of flourishing, and he’s found the four pathways to flourishing are – not surprisingly to all of us who work with patients – family, community, work, and education. He specifically talks about religious community, which is what the epidemiologic data sets often ask people about. So, the family is sort of obvious to us, right? When somebody is getting better from their illness or needs support in getting better from their illness it’s really important to getting well and staying well to have the support of family, and have those relationships, somebody that cares about you, somebody that you matter to, if your dead or alive it’s gonna matter to them, really important. It’s important for people recovering from addiction to have that support of family members. Often, they’ve burned bridges, so they have to rebuild those. We consider each of our patients from these four pathways. You know, what is the strength of their family ties? What ties do they have to the community? Do they need to be in AA or NA for a supportive community? Would it benefit them to reconnect to their faith community? We also look at the strength of their work. Do they have meaning and purpose in their work? Is there someone at work that depends on them? In terms of drug addiction, which, I’m addiction medicine certified, so I keep going back to addiction, but in terms of drug addiction, thinking about the positive reinforcer that work is and how it can compete with drug use if somebody is having meaning and purpose, and a pleasurable experience socially at work.  

And then the fourth pathway is education. It’s important for people to be able to read, and to be able to learn, whether it’sformal learning or informal learning, to be able to engage with the world that they live in brings meaning and purpose. It’san area where people can meet other people obviously. These pathways are relevant even to somebody who has a disease, right? If they have schizophrenia, their trajectory might be a little different than what had been expected. Somebody who got ill when they were at MIT, for instance, might have been on one trajectory. Now they have this very serious illness, and even though they might not be on the same trajectory, it can still lead a flourishing life. It can still lead a good life, but it's usually through these pathways, having a supportive family, being part of the community, getting meaningful work, and attaining the educational level that they desire and are capable. 

CHRIS AIKEN: There are a lot of patients that they’ve reached the limitation of psychiatric recovery – they are not gonna get better with a new antipsychotic, and what can we do for them further, is this how this works? 

MARGARET CHISOLM: Yeah, absolutely. I mean, first of all, I would never give up hope that somebody is not gonna get better with newer medications and with time, but I do think that as somebody is recovering or in a very slow state of recovery from an acute major mental illness they can still work on these pathways, and draw meaning from their relationships, whether it’s a partial hospital program or through a job training program, or through a sheltered workplace, or with engaging with the NAOMI community, there are many ways that people can lead meaningful lives even when they are ill. 

CHRIS AIKEN: If they take on those pathways, whatever medication they are on is likely to work better.  

MARGARET CHISOLM: Absolutely, well now I think that you would be more likely (I don’t have a study about this, but I’m just talking off the top of my head), but I do think you would be more likely to take your medication if you were leading a good life and there was somebody waiting for you at work, and if you didn’t take your medication you might not be well enough to go to work.  

CHRIS AIKEN:  Opens up a whole new way of talking about adherence, I imagine. 

MARGARET CHISOLM:  I think about that a lot in non-psychiatric medical specialties. If you have somebody who'snot taking their insulin for diabetes, and then you look at their life, and they're living alone, they have no family, they have no job, they have no place to be, nobody's depending on them. Why would they take their medication? If they're not leading anywhere near what any of us would agree upon as a good life, I mean, you have to work on those things first, and then give a person a reason to take their medication. I think it's very relevant to all of them. 

CHRIS AIKEN: I wonder how you open up education for patients because I imagine a lot of them are gonna think of that as whether or not they have a degree. You know, “I already did that. I got my degree." Like how do you open that up in the broader sense? 

MARGARET CHISOLM: I really think it’s about learning more than education, and I think to be able to learn, I think you need a basic education, a high school education; you need to be literate, but education can mean a lot of different things. It doesn’t mean a 4-year college degree or a 2-year college degree; it could mean learning a new skill, learning to cook, learning to garden; it really is about learning in a way that engages the mind so that it brings meaning, right? And sometimes these learning goals can also overlap with community goals, right? Because through learning a new hobby or skill you can become part of a community of other people interested in that.  

CHRIS AIKEN: A few months ago, I saw a paper suggesting that we view isolation as a disease because it’s associated with some many adverse health outcomes. Clearly, if it is a disease, there’s an epidemic going on, what’s your take on that? 

MARGARET CHISOLM: Yeah, so this is the flabby thinking calling everything a disease. So, the way I define disease is it’s a syndrome. It’s a cluster of signs and symptoms that run a course together that can be best understood as emerging from a broken part or function. So, isolation, I don’t think would meet that. I would say that isolation is best understood from the life story perspective and is different for different people. This is the interaction between dimensional perspective and the life story perspective. The people that have done the best during the pandemic are people who it’s not the introverts, which is what people might think, it’s the conscientious person did the best. They did the best because they could self-structure their time.  

CHRIS AIKEN: That does make sense. I noticed that my patients that were all doing better, were all going for walks everyday outside. I thought of it as nature, but it’s also conscientiousness, you’re right. 

MARGARET CHISOLM: Well, if you can devise a schedule for yourself, you don’t need that external work structure or whatever social structure that was imposed on you. I think it makes it a lot easier to cope with these situations. So again, that’s how I would see it. I would see it as best explained by the life story perspective, which, obviously, has interactions with other thing and could lead to a disease. It could be a stressor for you depending on what your personality is, and we know that increased stress makes it more likely to precipitate an episode of affective illness. Or it could be you are socially isolated, and you’re drinking more (I’ve heard that happen). 

CHRIS AIKEN: So, for isolation, you might say good target there but wrong lens, wrong perspective. 

MARGARET CHISOLM: Exactly. 

KELLIE NEWSOME: Margaret Chisolm is a professor of psychiatry at Johns Hopkins University. She has authored over 150 scientific papers and two books that explore the perspectives of psychiatry, one for professionals, Systematic Psychiatric Evaluation, and one for patients, From Survive to Thrive: Living Your Best Life with Mental Illness. A shortened version of this interview appeared in the March 2022 edition of The Carlat Report and is available online. Want to keep up with the latest in psychiatric research? We post new studies in the daily psych feed, search for Chris Aiken, MD, on LinkedIn, Twitter, Facebook, and that new one, BlueSky.  It's a first glimpse of the trials that inform this podcast. Thanks for tuning in and helping us stay free of industry support.