Integrative Mental Healthcare—one psychiatrist’s perspective

by James Lake M.D.

This website is directed at people who are interested in learning about the future of medicine. The articles and presentations you will find here discuss ideas and trends that are shaping the evolution of Western medicine toward new ways of thinking about causes of illness and diverse meanings of healing which are presently outside of orthodox biomedicine. Integrative mental health care is about novel ways of seeing, understanding and treating mental illness. Progress in medicine, as in any area of thought, takes place when there is openness to new ways of seeing phenomena associated with illness and health. In the absence of rigorous intellectual openness, those who hold on to orthodox models and medical practices often dismiss new ideas and new methods prematurely, before weighing the evidence. Medicine then risks becoming stagnant, politicized, and bounded by a closed set of beliefs and practices guided by entrenched ideologies. It risks becoming less scientific and more dogmatic. Some would contend that biomedicine has already crossed that line. However, many beliefs that were once accepted as “facts” or incontestable theories in biomedicine are now being seen as crude or incomplete understandings, and the “facts” of medicine are being re-written at an ever increasing rate.

Biomedicine is in a state of critical re-evaluation and rapid change. Recent progress in physics, biology and consciousness studies has stimulated fundamental research into basic mechanisms underlying normal and abnormal states of consciousness. Entrenched theories in biomedical psychiatry are being re-examined, and novel approaches to the assessment and treatment of mental illness are emerging. There is unprecedented openness to new ways of understanding ourselves and our place in the universe. Along with many areas of scientific inquiry, Western biomedicine is at the threshold of a remarkable period of evolution and transformation. Novel explanatory models of the causes, conditions or meanings of illness, health and healing are being explored and debated in leading academic institutions and also in popular culture. The study of consciousness has become an accepted field of academic research, leading to many novel hypotheses about the nature of mind and mind-body in space and time. The distinction between conventional understandings of “Mind” and “Body” is increasingly blurred, and the role of intention in healing has become a subject of serious inquiry. Many Spiritual traditions, including Yoga and Tibetan Buddhism, are providing a fertile testing ground for new models of physical reality and the causes or mechanisms associated with illness and healing. The result has been a dramatic shift in the kinds of questions that are viewed as legitimate to ask in conventional Western biomedical research. Progress in science has been described by Kuhn and others as an essential evolutionary process, a kind of reciprocal and self-reinforcing transformative dialectic between the ideas and institutions of science and the beliefs, values and skills of researchers and clinicians from many traditions. By this criterion, conventional Western biomedicine is clearly in a period of transformation in which entrenched concepts are being challenged by emerging research findings and novel ways of seeing the physical, biological and energetic processes that take place in nature and influence health and illness. Future students of history will view the present epoch in Western medicine as a period of rapid transition from long-held beliefs and practices embedded in 19th century scientific thought to theories and practices informed by 20th century science.

I believe there are appropriate and effective roles for both established and emerging approaches in medicine, both empirically derived scientific models and intuitive ways of understanding and treating illness. Many Western biomedical treatments of mental illness are effective, bringing relief to millions who would otherwise be unable to function or experience pleasure or meaning in life. Western psychiatry rests on a coherent body of theory, research and clinical data, and is the beneficiary of fundamental scientific advances in neurophysiology, pharmacology, molecular biology and genetics. However, the successes of conventional biomedical assessment and treatment approaches are limited by many factors, including: incomplete or erroneous understandings of the putative mechanisms of action of many drugs in current use; the limited efficacy of many drugs in current use; significant safety problems and related compliance problems caused by toxic side-effects or drug-drug interactions; un-affordability or limited availability (ie, because of high medication costs or poor insurance coverage) of many drugs that are regarded by Western medical practitioners as the most appropriate or effective treatments for a particular mental illness.

The above issues have resulted in enormous controversy over the appropriate uses of conventional biomedical treatments of mental illness, and I believe they limit the potential successes of many conventional treatments. A reasonable and necessary response to the inherent limitations of contemporary biomedical treatments of mental illness is the systematic evaluation of non-conventional assessment and treatment approaches in order to identify safe and effective approaches, and to find practical ways to increase the use of approaches that work. To that end, the American Psychiatric Association recently established a Caucus on Integrative Psychiatry. The Caucus represents the first APA-endorsed effort to evaluate non-conventional and integrative approaches in mental health care. The APA Caucus will eventually publish guidelines and organize training programs on the evidence-based uses of non-conventional and integrative assessment and treatment approaches.

In addition to the scientific and historical forces driving medicine toward novel ways of conceptualizing illness, many social issues will ensure the continuing evolution of Western biomedicine toward integration. In North America and Europe, changing personal beliefs about medicine and healing have resulted in increasing openness to non-conventional methods. The majority of “medical consumers” in Western countries use both conventional and non-conventional methods for prevention or treatment of health problems. The average consumer of non-conventional medical practices is better educated than individuals who use conventional medical services only; is satisfied with the conventional care she receives and uses it together with at least one non-conventional therapy; has a “holistic” orientation to health; expresses strong commitments to personal growth or spirituality; and probably has a history of either chronic pain or anxiety. The growing acceptance of non-conventional medical practices in Western countries reflects an increasingly consumer-driven health care environment in the context increasing medical diversity. At this time in the history of Western medicine, there is considerable tension between factors pushing medicine toward pluralism and factors driving medicine toward increasing integration. Medical pluralism is the dominant model of health care in the U.S. and most Western countries today. In this model, disparate systems of medicine co-exist relatively independently of one another, and most health care professionals are trained in one system of medicine and practice only one kind of medicine.

Health care professionals trained in one system of medicine sometimes refer patients to practitioners of other medical systems, but patients more often pursue alternative approaches on their own initiative and usually without the guidance or consent of their primary medical provider. In the background of medical pluralism, there is a steady trend toward integrative approaches to medical and mental health problems. Both conventionally and non-conventionally trained medical professionals are increasingly becoming qualified in more than one system of medicine. In Western countries, clinics and hospitals commonly offer patients a range of biomedical and non-conventional treatment choices. On the side of continued medical pluralism are the economic interests and established traditions of the institutions and practitioners of several already dominant systems of medicine, including Western biomedicine, Chinese medicine, Naturopathic medicine, Western herbal medicine, and increasingly, homeopathy and Ayurveda. On the side of the trend toward increasing integration are governments, managed care organizations, and medical insurance providers who are driven by shared economic interests in managing the complex healthcare needs of patients in efficient and cost-effective ways. In some settings and for certain medical or psychiatric problems, patients likely benefit more from the prevailing pluralistic structure of health care, while in other settings and for other medical problems, emerging integrative health care more adequately addresses patient needs. Broad future directions in the evolution of medicine toward increasing pluralism or increasing integration will ultimately depend on the interplay between competing economic and social factors and widely held values that reflect diverse priorities and perspectives of patients, governments and the “business” of health care.