An “ integrative holistic approach to psychiatry,” by the very act of naming it as such, is inherently a critique of mainstream psychiatric care. It is generally presented as mental health care for “the whole person,” in contrast to what “non-integrative or holistic” psychiatrists are assumed to do: identify symptom clusters that conform to the diagnostic categories of the neo-Kraepelinian DSM-5-TR nosology, then use pharmacology and other evidence-based interventions (ECT or rTMS, for example) to reduce or eliminate the presumed chemical imbalances that gave rise to those symptoms. Truth be told, neither characterization is accurate. Binaries are overly reductionistic, and ignore the fact that the vast majority of psychiatrists are conscientious doctors who care for whole people, not just their brain chemistry. It may be better, then, to see integrative care and holism as a spectrum of philosophical orientations. At one end, care is oriented toward the microcosm: dysfunctions within the brain and individual behavior. At the other, care extends macroscopically toward a more expansive understanding of human suffering as the result of dysfunctional relationships within a greater ecosystem, one that includes the culture and physical environment in which a person lives.

In my own practice, I lean toward the latter. I give deference to a century and a half of research that has identified, organized, and found treatments for the constellations of symptoms with which patients present. I also see suffering as the result of a galaxy of factors emerging from problematic interactions among a person’s biology, psychology, spirituality, and ecology. The more I can learn about a patient and their life story, the better I can care for them. I regret to inform the ABPN that I spend far more time than the standard DSM-style diagnostic interview allots listening to and trying to understand the complex, painful, beautiful, and profound stories that each person asking for my help brings to me. Like most doctors, I ask patients to bring their lab data, family histories, and medical histories. Unlike most, I suspect, I also invite them to bring their artwork and their poetry, and to share, to the best of their ability, their phenomenology: the lived experience of what it is like to be them. This invites the whole person into my clinic, rather than just the illness.

When it comes to treatment recommendations, I try to meet three criteria:

1. Evidence of benefit. As much as possible, any recommendation should carry some evidence that it works. Throughout history, humans have constructed complex systems of healing based on a priori assumptions derived from their native ontologies. These systems not infrequently offer real relief, but it is better still to have objective data demonstrating their benefit.

2. Benefits that clearly outweigh costs. The benefits should exceed the costs by a significant margin. And where the benefits are unclear, the risks should be as close to zero as possible before I will recommend a treatment.

3. Sustainable integration. Any treatment must fit into a patient’s life in a way that supports rather than interferes with their well-being. Ideally, it is something the patient genuinely wants to do, because no treatment works, no matter how good it is, if a patient will not use it.

My approach to integrative care and holism also requires that I maintain a high degree of epistemic humility. The whole contains both what is known and what is unknown. A human brain is the most complicated thing we currently know of in the universe, and no amount of training or reading of peer-reviewed literature changes the fact that helping it work better demands profound humility. One of my greatest teachers put it this way: in spite of all the research we have done, psychiatry remains very much an art, and less of a science than we would like to believe.

How I Work with a Patient

I begin with time. Before our first meeting, patients complete an intake form with questions about sleep, diet, relationships, and sources of meaning. I read it looking for who they are: their word choices, the rhythm of their narrative, what they emphasize and what they leave sparse.

I look for patterns, but I hold them as hypotheses to be tested rather than conclusions upon which to build treatment plans. I know that I am biased and my mind is limited, and as such I do my best to maintain epistemic humility and genuine curiosity about the story of suffering my future patient shares.

In our first sessions, often spread across two or three hour-long visits, I deepen and clarify what they’ve already shared with me. I listen to the tonalities beneath the words: where their voice resonates with aliveness, and where it flattens. I notice the harmonies and dissonances within their narrative, between what they say about themselves and how they say it, between their relationships and their sense of meaning, between their biology and their lived experience.

Between visits, I distill what I have heard into updated working hypotheses, organizing the story into four domains: biology, mind-body connection, interpersonal psychology, and spirituality or their pursuit of eudaimonia. At our next meeting, I bring these hypotheses back candidly, as proposals for thought partnership and together, we decide what to explore further, whether through laboratory testing, shifts in sleep, exercise regimens, diet, psychotherapy, or other practices, and we build a plan that fits inside their actual life. And because the relationship itself is part of the medicine, I never take the quality of our dynamic for granted.

Treatment Options

Given that suffering often emerges from decades of problematic interactions across biology, psychology, mind-body connection, and meaning-making, I share candidly with patients that recovery will take time. Patience will be the hardest—and most essential—thing we ask of ourselves in this work. I present treatment as a spectrum of options rather than prescriptions. Each carries an effect size; some work quickly, others slowly. I begin by naming the foundations:

• Diet

• Sleep

• Exercise

These are the least exogenous interventions and the closest to how a human body naturally thrives and they often create the conditions for deeper work.

From there, the toolkit expands.

• Psychotherapy, specifically psychodynamic approaches.

• Dietary supplementation guided by testing and intention.

• Sleep assessment using wearable technology.

• Coaching.

• Neurofeedback and biofeedback.

• Mindfulness-based stress reduction and other contemplative practices.

• Breathwork, including holotropic breathing and similar techniques.

• Ketamine-assisted psychotherapy.

This last one is not a one-off intervention but part of an ongoing psychotherapeutic journey. It requires preparation before treatment, the experience itself, and careful integration afterward. I think of it as a tool for translation: the insights that emerge in the ketamine state need to be brought back into real life, woven into ongoing therapy, sometimes revisited over months or years as the work deepens. Used this way, it becomes part of a larger arc of healing rather than a discrete event.

Summary

In the end, I am not certain that “integrative” or “holistic” are the right word for any of this. It remains, as I said at the outset, words defined partly by what it claims to oppose. What I can say is that the person who comes to my clinic is more than the sum of their symptoms, and the suffering they carry is more than a malfunction to be corrected. They carry many sacred, heavy stories that they have been unable to share for enough time to cause them pain. My work is to listen well, to hold my hypotheses lightly, and to offer what millennia of healing wisdom and what a century and a half of modern medicine has learned. I do this as a partner paying deference their autonomy, because the person in front of me is the only true expert on what it is like to be them. The art of psychiatry, as my teacher taught me, is an elegant description of the work itself. An art asks for patience, humility, and relationship. So does healing. And when we practice it that way, together and over time, people often get better. Not because we eliminated the unknown, but because we made room for the whole of them, the known and the unknown alike.

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In my previous three essays, I identified challenges that I think are at the core of mental healthcare today.

In the first essay, I told the story of my colleague who left her private practice because she no longer found fulfillment fighting against a medical system shaped by clinician burnout, practice consolidation, insurance bureaucracy, rising demand, and an information environment lacking trustworthiness. These factors, which aren’t unique to her experience, made her work of healing others more transactional, less human, less meaningful, and ultimately unsustainable.

In the second essay, I presented my hypothesis on the meaning of the statement, “I didn’t feel heard,” and how it might point to the need for reciprocal relationships in healing dynamics. Specifically, in most healthcare settings, patients are passive recipients of medication, therapy, or guidance. This unidirectional, hierarchical relationship fosters transactional dynamics with healthcare practitioners. I proposed an alternative: people feel healthiest when they see that their personal healing has had a positive and meaningful impact on their families, their communities, and the wider world.

In the third essay, I provided the reader with my professional background, telling the story of my path through the Department of Veterans Affairs, the Santa Clara County Valley Medical System, and a multi-specialty private integrative medicine practice. In the retelling, I shared some of the lessons I learned along the way — the healing power of service, the resilience created by communities of care, and the intellectual richness of multidisciplinary collaboration.

In this essay, I weave these threads together to describe the model that we’re using at our mental healthcare clinic.

One Clinic at a Time

The American mental healthcare system isn’t working well. Practitioners aren’t thriving, patients often don’t feel better, it costs too much, the care provided doesn’t translate into improved population-based health outcomes, and the disconnect between the actual medical research and the public’s understanding of that research is widening daily. In this essay, I offer one possible answer to what I see as essential failure points in mental healthcare: imbuing the work of healing with meaning, agency, trust, and shared purpose for everyone involved.

The solution begins with five core tenets:

1. Eudaimonia (human flourishing): Whether you are a patient, clinician, non-clinician, or community member, the goal of our clinic is to create an environment that can help you flourish.

2. Patients as Active Participants: Patients are active teammates in the care they receive, and are engaged contributors to the work of health and healing.

3. Practitioners as Contributors to the Noble Tradition of Healing: The calling a practitioner hears to become a member of the healing professions includes, but is not limited to, patient care. As such, only when their impact reaches beyond the walls of the clinic, through scholarship, mentorship, and advocacy, can they feel that they have answered their calling.

4. Non-Practitioners as Essential Partners: It is necessary to recognize that non-practitioners who work in healthcare settings may have also heard a call to become healers. As such, a successful clinic must give non-practitioners the ability to answer that call by becoming partners in program development, clinical governance, and through appropriate patient engagement.

5. A Clinic as Part of a Larger Ecosystem: What we do in the clinic must have a real-world impact, and that impact must reflect the needs of the greater community. Creating a clinic that focuses on mission over profit allows all participants — practitioners, non-practitioners, patients, and the greater community — to participate in the important work of healing in an ethical, equitable, and just manner.

Together, these tenets dictate how the clinic is staffed, how care teams are organized, how patients participate, how practitioners are supported, and how the clinic relates to the communities it serves. Let’s describe each of these in greater detail.

1. Eudaimonia — “We Heal When We Flourish Together”

In an earlier Substack piece, Eudaimonia, I reflected on the ancient Greek idea that the highest goal of life, human flourishing, is achieved by cultivating one’s innate abilities and using them for the benefit of the wider world. This is the animating spirit behind the clinic we’ve created: an environment in which flourishing, or eudaimonia, is the goal, and where patients, practitioners, non-practitioners, and the wider community contribute to one another’s flourishing.

2. Patients as Active Participants, Scientists, and Healers

Like other clinics, we care for patients. We differ, however, in three important ways.

First, we define the goal of care from the outset: to help people pursue eudaimonia by identifying and cultivating their vital forces, those innate qualities, capacities, and sources of meaning without which they would no longer feel fully themselves. We then create a plan to reduce the biological, psychological, and social barriers that limit their ability to engage with those vital forces and lead a flourishing life. This approach gives patients and practitioners a shared vision of what “better” looks like through the unique lens of each patient’s life. It also transforms the experience of receiving care from one of passivity and transaction to one of active engagement in the purposeful, relational work of healing.

Second, we use a patient-led collaborative care model where patients are members of a team that includes a medical practitioner (i.e., psychiatrist or psychiatric nurse practitioner), a mental health practitioner (i.e., psychotherapist or coach), and a non-clinician team member (or eudaimonia advisor). These teams first meet during the intake appointment and reconvene at monthly or quarterly intervals, bringing complementary perspectives to the patient’s experience and healing journey. Additionally, diagnosis and treatment recommendations emerge through collaborative consensus rather than being imposed through traditional clinical hierarchies. Finally, this approach provides patients with multiple, interconnected lines of communication for when concerns or questions arise between appointments.

Third, as discussed in essay two, one feels heard when they hear, and one feels whole when they help others achieve wholeness. As such, in addition to receiving care, patients are invited to participate in the clinic’s scholarly activities, in community service, and in peer support. In this way, patients, practitioners, and the community all heal and flourish together.

3. Practitioners as More Than Clinicians

Burnout is about more than practitioners feeling overworked. In the current paradigm, practitioners are seen as units of production and, as such, are asked to see more patients, make diagnoses more quickly and accurately, and bill at higher rates in order to generate more money. Recognizing the problems this creates for practitioners and the system as a whole, our model sees practitioners as curious, passionate, ambitious, and relationship-oriented people who go to school for advanced degrees because they want to care for patients and contribute to something bigger. We’ve created an environment where practitioners can do exactly this: provide exceptional mental healthcare as part of a collaborative team while pursuing clinic-supported scholarship, mentorship, and advocacy alongside their colleagues. Additionally, unlike some organizations that prioritize mission over employee mental health, practitioners are paid fairly in a system that does not require that they sacrifice their well-being for the clinic’s. In this model, practitioners can answer their calling in a rewarding, fulfilling, and sustainable way.

4. Non-Clinician as Eudaimonia Advisors

I’ve been humbled by the time, care, and support that non-clinical co-workers freely offer patients on their healing journeys. Whether offering hope to someone calling to schedule a first appointment, making a cup of tea for a tearful patient in the waiting room, or sharing a personal story of resilience, non-clinicians play an essential, though often unrecognized, role in healing. It is not hard to imagine that many choose to work in healthcare because they feel a calling to serve, and because they sense that the exercise of their own vital forces can meaningfully improve patients’ lives.

Too often, this sincere effort goes unrecognized at best and penalized at worst. Sometimes, the strength of this calling leads staff members to pursue clinical training in medicine, nursing, counseling, or coaching because they believe that the only way they can “truly” help another person heal is by obtaining a clinical credential. Others pursue coursework or certifications in public health, community advocacy, communications, finance, or human relations because those are the domains in which they feel their abilities can best serve the broader mission of healing.

But what if a clinic could provide these individuals with a proper professional home? What if they could appropriately and meaningfully contribute to the larger work of healing without feeling that they missed the boat, or that they must earn a degree before they are allowed to help others?

As with patients and practitioners, non-clinical staff are also engaged in the pursuit of their own flourishing. In addition to doing the work necessary to keep a clinic operating, they play several essential roles in the healing ecosystem. First, they participate in patient assessment by offering an additional perspective that the clinical team and patient may have missed. Second, they serve as a bridge between the clinic and the community, drawing on the relationships, interests, and commitments that are part of their own flourishing. Third, they become a touchstone within the clinic, a trusted member of the team who helps connect patients, practitioners, and community resources in an organic and relational way.

Through this model, non-clinicians are not treated as peripheral support staff, but are invited to become eudaimonia advisors: valued members of a larger healing team whose contributions are recognized, supported, and integrated into the work of care.

5. The Clinic as a Microclimate in a Larger Ecosystem

Our clinic exists within a larger community, and as such, it must participate in dialogue and partnership with that community. Beyond providing innovative mental healthcare to individuals in need, we commit to sharing what we have, what we know, and what we continue to learn. We intend to do this in a variety of ways, including through in-person and virtual classes for the public, educational and training initiatives for practitioners, and advocacy focused on broader unmet mental health needs.

Affording Scope

A model like this cannot be infinitely broad. It needs a defined domain of focus, both to preserve coherence and to avoid becoming vague or overextended. For us, that focus is the rational use of psychedelics in mental healthcare. This focus emerged organically from the shared interests of the practitioners and non-clinicians who helped shape the clinic from its inception. Each of us, in different ways, is committed to enriching the public discourse around this question.

Other clinics adopting the model would not need to share this same focus. They might choose to direct their vital forces toward family-focused postpartum mental health, comprehensive cancer survivorship, dissociative identity disorders, or another area of need. Not every clinic can serve every need for every patient, practitioner, and eudaimonia advisor. But I believe that a clinic can reasonably exist, and perhaps thrive, when it voluntarily limits its scope to the study of, education about, advocacy for, and treatment of one specific area of need.

To be sustainable, a clinic based on this model requires a different kind of financial structure reminiscent of those used by academic medical groups. Specifically, the clinic can provide affordable care, maintain its commitment to scholarship, teaching, and advocacy, and preserve its ethical commitment to human flourishing over profit maximization only if it maintains a diverse set of income streams. This can include clinical revenue, educational workshops, grants, and philanthropic donations.

Words of Caution

This model does not eliminate the ordinary constraints of clinical care. Patients still need clear treatment plans, clinicians still carry professional responsibility, non-clinicians still need defined roles and supervision, and the clinic still has to meet payroll. The claim is not that meaning replaces structure; rather, that structure should be built in the service of meaning.

This model is also not a rejection of diagnosis, medication, evidence-based care, or professional expertise. It is not an argument that every patient must embrace psychedelics or become a researcher, advocate, or peer healer. It is not an attempt to erase clinical boundaries or pretend that every member of a care team has the same training or responsibility. Rather, it is an attempt to build a sustainable clinic where all members have a shared vision of mutual flourishing.

Proof of Concept

We’ve begun to do this work at my clinic. True to our commitment to eudaimonia, the clinical and non-clinical staff at my clinic are actively supporting each other’s and our patients’ flourishing. Within the past year, this work has included:

• Cared for over 200 patients

• Created and piloted an innovative approach to patient-led collaborative care

• Developed and implemented a ketamine-assisted psychotherapy (KAP) protocol through our partnership with Avesta Ketamine Wellness

• Chaired the Substances Committee and authored source material for the final report of the Maryland Task Force for the Responsible Use of Natural Psychedelic Substances

• Published a paper on the ethical and legal considerations of at-home ketamine use

• Created four pre-recorded lectures for Palo Alto University’s course on psycholytic ketamine assisted psychotherapy

• Served as an expert on a Delphi consensus panel focused on developing clinical guidelines for emergent phenomena

• Cultivated relationships with local, national, and international organizations involved in rational psychedelic use.

Your Thoughts Please!

Now I’d like to turn the conversation outward. This model may sound radical, utopian, and even uncomfortable. That discomfort is worth examining. Where does this vision resonate with you? Where does it feel misguided? And where might there be uncomfortable truths worth exploring further?

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On the road rising up to meet us

As it cuts through the forest from Tupper lake to Saranac,

We drive to town for coffee in early, frosted May.

Tall pines standing over the balsams - loving parents, branches like arms on evergreen shoulders.

Brave bright lime buds and the almost imperceptible reds of the birches and cherry trees,

Having just felt the first wa…

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Like children, careers rarely color within the lines — mine certainly didn’t. Fresh out of residency, I took, what I though, was a dream job — a medical directorship position at the Department of Veterans Affairs. Though I was reassured by the recruiter and my future boss that, even as a newly minted psychiatrist, I would be a great fit for the role, in retrospect I might have reconsidered had I known then what I know now. There, I encountered the complexity of aligning goals that stretched from Congress and the President all the way to the needs of individual veterans and their families. In that context, healthcare delivery emphasized efficiency within a system modeled on a hierarchical military structure. In my role, I balanced the needs of roughly two dozen psychiatrists, psychologists, social workers, and counselors with treatment timelines, outcome measures, utilization reviews, and structural reorganizations.

Even with the soul-crushing bureaucratic burden of the position, I found (made) time to design a peer group treatment initiative with a PhD-candidate, who also happened to be a veteran. We based the group on the simple yet powerful idea that some of the skills essential to survival and effectiveness while in uniform such as “Camaraderie & Cohesion,” and “Situational Awareness,” could be adapted to life out of uniform. This framing allowed veterans to reinterpret their experiences and current symptoms in a more empowering way, helping them successfully apply those hard-earned skills to civilian contexts.

Through my clinical work with veterans and my participation in this group, I came to understand something profound: rather than using medication and psychotherapy to help veterans gain relief from the suffering they experienced while serving, caring for veterans required that I understand the meaning of their suffering. Most, having felt a genuine calling to serve the country that had given them opportunities, understood and accepted the risks of enlisting. As such, they understood their symptoms differently than I, a civilian psychiatrist, did. As such, I learned that even out of uniform, their commitment to a mission of ongoing service played a central role in their healing.

Perhaps sensing that I was burning out, after about two and a half years at the VA I felt like I needed to move on to my next professional adventure. Although I had chosen to be a psychiatrist, my initial interest in medical school had been family medicine and I felt drawn to refresh those broader medical skills while continuing psychiatric work. When an opportunity to work as the intermediary between a behavioral health service and a primary care clinic became available nearby, I jumped at the opportunity.

This position was embedded in one of the largest county healthcare networks in the nation, and served a complex and diverse population. I quickly appreciated that my role was something of a pressure valve for an overstretched system. I helped transition psychiatrically stable patients back into primary care while also temporarily holding patients in crisis who had never seen a psychiatrist until outpatient services became available.

Unlike the more stoic culture of service I experienced at the VA, the camaraderie among providers and staff here was palpable. We celebrated birthdays and weddings together, and we supported one another through divorces, illnesses, funerals, and retirements. That sense of community created resilience in our work and gave us the emotional bandwidth to meet patients’ needs within a system that, like many public health systems, seemed like it was always on the edge of buckling.

Another defining feature of this role was the diversity of the clinical domains I could work within. Beyond my primary responsibilities, I spent nights and weekends in psychiatric emergency services, provided peer oversight at the community jail, worked shifts on the inpatient unit, and served as a consultation-liaison psychiatrist when needed. This broad scope of work gave me the chance to flex all my psychiatric muscles, which was professionally exhilarating and intellectually fulfilling.

After a little more than two years, I returned to the DC area to be closer to my family to support them in their own healing journeys. Having a background in integrative medicine and a holistic approach to care, I took a position as a psychiatrist at the GW Center for Integrative Medicine, where I quickly built a practice focused on psychotherapy and integrative mental healthcare. This included the expected components of psychiatric practice, but also approaches at the cutting edge of medicine including genetic testing, functional medicine workups, medical technology consultations, herbal medicine integration, and IV ketamine infusions.

Similar to the position at the county healthcare system, the GW Center for Integrative Medicine had a culture of camaraderie and diverse practice opportunities; however, it distinguished itself through its multi-practitioner, multidisciplinary model. This was best seen at team meetings where I sat alongside a world-renowned leader in functional medicine, two naturopathic doctors, three acupuncturists, a Reiki practitioner, a spiritual healer, a nutritionist, and a tai chi master. Together, we examined patient cases through different, and sometimes contradictory, lenses. It was exhilarating to think about health and healing so comprehensively and the result of this kind of collaboration was incredible, spanning treatment recommendations that included chemotherapeutic agents, detoxification pathway support, energy healing, spiritual alignment, and community reintegration. Truly what I, as a patient, want my care to look like.

At the same time, I quickly realized how time-intensive such deliberation could be. I often had to leave meetings early to see scheduled patients while the discussions continued in full swing. While inspiring in its depth, this model struggled to align with the financial and scheduling realities of conventional clinical practice. For me, the ongoing challenge became balancing the intellectual richness of collaborative care with the practical demands of patient access and sustainability.

One notable feature of these meetings was that patients themselves were almost always absent. This isn’t unusual as almost all clinical case conferences occur without the patient present. Still, it reinforced a dynamic where patients remained recipients of decisions rather than active contributors to them. Though the status quo, one might imagine that a truly collaborative model would invite patients into these conversations, allowing real-time revision of how their conditions are understood. This distinction between collaboration about a patient and partnership with a patient became increasingly important to me.

In December 2020, about a year into the COVID-19 pandemic, I started Washington Integrative Mental Health Services, with the hope of building a larger practice that applied the lessons I learned from each stage of my career. Through messy but colorful trial and error, I began synthesizing these lessons: the healing power of service, the resilience of communities of healing, and the intellectual breadth of integrative collaboration. In my next essay, I will lay out what I hope will be the basic framework of what such a practice could look like.

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As a psychiatrist who takes joy in the work of understanding the complexity of a person’s whole life, you might imagine patients gravitate toward my practice seeking a doctor who will listen to them. It should come as no surprise that I often hear about the frustrations new patients felt in their work with previous psychiatrists. Specifically, how they had felt that their last doctors weren’t able to hear them when they shared the history of their suffering and how “cold and clinical” their psychiatrist was as they provided their treatment recommendations. Germaine to my last post, it’s not uncommon to encounter healthcare providers who are checked out or who practice within scripted and restrictive systems that do not afford the time or emotional space to hear anything more than the superficial elements of a person’s medical condition. It’s also not surprising that providers offer rehearsed narratives about how simple solutions, like medication, can remedy complex problems - “you have a chemical imbalance…” With this in mind, it makes sense that patients look for doctors whom they hope will hear them as they seek to heal their deepest wounds.

Looking deeper, this feeling of being unheard isn’t limited to the people who come to my clinic. Patient satisfaction data repeatedly show that standardized, time-pressured care models leave patients feeling disengaged, which can result in worse health outcomes. Surveys on physician-patient communication often indicate that a core driver of dissatisfaction is the absence of collaborative decision-making, where patients are told what to do to achieve specific health outcomes, such as lowering their hemoglobin A1c by eating healthier, without fully understanding or shaping the meaning of those goals or recommendations in the context of a patient’s life. My friend and colleague, Lucy McBride, explores this problem within primary care medicine in her new book Beyond the Prescription. (Shameless plug)

Sadly, given the current state of medical care, not feeling heard is more-or-less what we can come to expect when we seek care in a mainstream setting. Interestingly, I’ve also heard this frustration from patients who’ve been referred by clinicians who don’t work directly within restrictive systems and who are (IMHO) exceptional listeners, healers, and practitioners. Indeed, it’s become a rare pleasure for me to hear a patient say, “I loved my last doctor, they really heard me.” As such, it’s made me wonder if this problem goes beyond time constraints, a lack of focused presence, wounded doctors, or a medical system without bandwidth. Perhaps the complaint of “not being listened to” actually points to a deeper question: what does it mean to be heard?

I think the answer can be found, at least in part, in David Abrams’ powerful and beautiful book, Spell of the Sensuous. In it, the author presents the work of the 20th century French Philosopher, Maurice Merleau-Ponty who explored the senses through a phenomenological lens. Merleau-Ponty articulates that the experience of sensation – seeing an object, hearing a sound, or smelling an odor – isn’t a passive-receptive act, rather it is an active reciprocal communion with the sensed. An image, sound, or touch isn’t projected onto a blank screen in our minds where we experience it as a sensation. Instead, sensing requires that we fundamentally and irrevocably change the matter of our brain by synthesizing new chemicals, transforming neuronal signaling patterns, and re-wiring neural networks that allow us to directly engage with the meaning of the sensory input presented. Only through this engaged transformation, then, do we actually see, smell, feel, taste, or hear the objects of perception. The work of active tuning and not the sensory information itself is what we sense in a world that would otherwise be filled with meaningless noise. To quote Abrams:

Participation is a defining attribute of perception itself. By asserting that perception, phenomenologically considered, is inherently participatory, we mean that perception always involves, at its most intimate level, the experience of an active interplay, or coupling between the perceiving body and that which it perceives.

Applying abstract philosophy to the patient experience, to feel heard, the patient needs to experience a relational active interplay between the doctor and themselves. Stated in a different way, a patient feels heard when they tell their doctor about their suffering and yearning to heal, and they experience their empathic doctor as suffering and yearning to heal with them. As such, hearing a patient must be more than simply listening to questions about which test to order or whether to take a medication based on the patient’s input. Instead, it happens when a patient knows that their suffering isn’t just theirs alone and that they, along with their doctor, take responsibility for the shared work of healing.

With this in mind, let’s think about the patient’s role in the work of healing. Just as the experience of being heard in a practitioner-patient relationship is a mutual co-participatory act, so too is healing. Though the training and experience a doctor has received has made them equipped to help a patient heal, if it’s only the doctor acting on the patient’s wounds, the patient subordinates themselves, ceding part of their agency and their contribution to a reciprocal relationship. In this way, patients can find that they’ve sacrificed their authority, their will, their voice, and their innate healing ability to their healthcare practitioner. As a result, they can find themselves feeling ignored, misunderstood, and even bullied into treatment decisions they don’t feel comfortable making. Conversely, if patients approach the relationship with their doctors as one that provides them with opportunities to exercise their vital forces of healing and expands their scope of what it means to be healed for both themselves and others, patients approach their own healing from a more powerful position.

As strange as it may sound, our medical system unintentionally facilitates this by having the patient heal their healer through paying doctors for their doctoring work. Just as we feel valued by receiving money, we convey the value we feel for others by paying it. So, by handing your credit card to your doctor, you indicate that you value them, care about their wellbeing, and want them to be healthy. Unfortunately, this gets lost in the translation of the transaction. Specifically, if payment is the only permitted way for a patient to be in an active, caring relationship with their healthcare practitioner, they can feel exploited, frustrated, or excluded, especially if payment means sacrificing other healthier parts of their life.

As a psychiatrist who has spent most of my career in clinical practice, I have experienced this first hand. Patients sometimes seem to worry that their payment doesn’t convey the care they have for me. This can take the form of apologizing for being late, offering a gift from their travels, or communicating that they need to protect me from their emotional traumas out of concern that it might, somehow, injure me. In our training, we are taught to pay attention to these psychological dynamics and compassionately explore them in therapy. Additionally, we are reminded that when the meaning of this desire to care is misconstrued and when boundaries are ignored in the doctor-patient relationship, the results can be catastrophic. Nonetheless, the persistence and ubiquity of this dynamic confirms to me that, only when patients feel that they can meaningfully contribute something of themselves to the healing of others, can they change from being passive-receptive healthcare recipients to active participant-contributors in communion with the sacred work of their healing. Stated more succinctly, by helping others heal, you heal yourself.

This essay is theory and philosophy heavy, and as such, it doesn’t translate easily into something you could imagine seeing in your doctor’s office. Additionally, it might raise concerns about healthcare systems that ask patients to give something of themselves, other than money, in order to heal. This is especially concerning in instances where individuals have been exploited or have already made significant sacrifices of their time and resources to access care. I spent a lot of time thinking about whether or not to put this into the Substack ecosystem because of my concerns with how the message could be misinterpreted. Aware of the risks, I think that the core idea of this essay - being heard and healed is best achieved by hearing and participating in the healing of others - is one worth sharing.

I’d like to describe a practical model I’m envisioning for the next iteration of my clinic that embraces this idea. Before I do, I’d like to share my own “doctor story,” so you can see how I arrived where I did.

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In a recent conversation with a doctor colleague, I was taken aback when she told me that she was leaving her private practice for a “less administratively burdensome” position at a local urgent care. This was shocking to me as I not only relied on her brilliance for clinical guidance on complicated cases, but also admired her incredible administrative skills, which made it seem like she had mastered the busy work of being a doctor.

As we talked more about her decision, she reflected on what she experienced as the dehumanizing nature of a profit-centered healthcare model and the difficulty she had finding time to engage in the kinds of thoughtful, interesting work that had originally drawn her to a career in medicine. “It wasn’t burnout, per se,” she said, “rather a growing recognition that I couldn’t be the healer and scientist - really, the person - I had dreamed of becoming since childhood.” Despite the incredibly meaningful impact she had on her patients’ lives, the way she had to practice medicine to pay for her mortgage made her feel like she had to abandon the compassionately relational, deeply curious, and intellectually-driven parts of her identity that made her want to be a doctor in the first place.

My friend’s decision is not an outlier. It sits atop several converging trends: persistent clinician burnout, accelerating consolidation of medical practices, insurance-mediated friction in everyday care, a growing and aging patient population, and a changing information environment that has diluted physicians’ perceived authority. Though many readers are likely familiar with these challenges, I’d like to provide a brief overview for those of you who may not be.

Burnout

When healthcare providers open up about the emotional work of their practices, they often compare notes on how burned out they feel. Burnout refers to a work-related syndrome characterized by emotional exhaustion, depersonalization toward patients, and a diminished sense of professional effectiveness, often driven by sustained administrative burden, time pressure, and loss of clinical autonomy. This issue was already on the radar prior to the COVID-19 pandemic, but then became a major focus during the pandemic, when our healthcare system faced unprecedented strain.

Beyond the personal suffering it causes, burnout directly affects provider productivity and patient outcomes. As you might imagine, a burned-out doctor has a much harder time being a caring doctor, and a doctor who has a hard time caring isn’t really in tune with their patients’ needs. That means less listening, and, unfortunately, more mistakes and lower quality care.

What causes burnout? This question has been the source of debate for a while, but I think the simplest explanation is that there are fewer available resources for both doctors and patients than there were a few decades ago. Another way to say this is that the medical system became “leaner.” Less time per patient. More patients per provider. More regulatory and administrative requirements. More boxes to check. Less time to collaborate. More work brought home. More focus on dollars and metrics. Less focus on alleviating suffering, building relationships, and growing professionally.

Though surveys suggest burnout has improved from its pandemic peak, it remains high enough to be destabilizing. According to the American Medical Association (AMA), while the percentage of physicians reporting at least one symptom of burnout decreased between 2021 and 2023, it remained high, landing in the high 40 percent range in 2023. Medscape’s 2024 report similarly places burnout at roughly half of physicians, depending on the measure used.

Let’s reflect for a moment. Up to half of doctors are reporting some degree of chronic depletion, and who knows how many stoic neurosurgeons are biting their tongue. Even with improvement since the height of the pandemic, a substantial portion of the workforce is impaired. Chronic depletion changes career decisions. It shortens time horizons. It transforms “I can easily do this for another decade” into “I will try to do this for another year.” It makes caring for one more person feel like a question about whether one can continue caring for oneself. This is not sustainable.

Consolidation and the loss of local control

Practice consolidation amplifies these pressures. As physicians move from independent ownership into employment or affiliation with larger systems, decisions about staffing ratios, visit lengths, scheduling density, documentation templates, and quality metrics migrate upward. The U.S. Government Accountability Office reports that at least 47 percent of physicians were employed by or affiliated with hospital systems in 2024, up from under 30 percent in 2012.

Consolidation can bring resources and infrastructure, but it often comes at the cost of autonomy. Production pressure increases. Compliance work expands. The physician subtly shifts from an independent professional guided by their own personal interests and values to an operational node within a revenue engine. For some, that shift is tolerable, or even favorable. For others, it corrodes the very identity that drew them into medicine.

Insurance-driven care and administrative drag as a toxin

Ask almost any physician what the least enjoyable part of their job is, and prior authorization will likely rank near the top. It’s the demoralizing act of calling an insurance company to essentially beg them to pay for a medication or treatment you’ve already determined your patient needs. The AMA’s annual survey on prior authorization documents widespread delays, negative clinical consequences—and in some cases—serious adverse events tied to coverage barriers. It also reports that patients frequently abandon recommended treatment because of these hurdles.

Administrative work does not merely consume time. It interrupts the moral arc of the day. When clinicians spend hours on documentation, peer-to-peer calls, denials, and appeals, their work becomes a series of obstacles between intention and care. That is precisely the dehumanization my friend described.

A growing and aging population

Even if the system were emotionally sustainable for providers, demand is rising. The Association of American Medical Colleges projects significant physician shortages in the coming decade, driven largely by population growth and aging. By 2036, the U.S. population aged 65 and older is projected to grow dramatically, with even faster growth among those over 75. The projected shortfall could reach up to 86,000 physicians.

More patients with higher acuity interacting with a workforce already stretched thin creates a simple arithmetic problem. Wait times lengthen. Continuity erodes. Temporary staffing models expand. We were warned in medical school that this was coming and that the inelastic system would eventually be overtaxed to the point of snapping. It is difficult to argue that it hasn’t already arrived.

Authority and the Internet

Finally, the physician-patient relationship itself is being renegotiated in the “post-truth” digital age. In part because many patients feel unheard or rushed, they turn to the internet for answers. There, they encounter both a mix of high-quality information and confident misinformation, the latter often delivered with certainty and charisma. AI compounds this problem as worried patients turn to, and develop trusting relationships with an omnipresent, seemingly omniscient, and emotionally affirming source of information that seems, well, better than human health care providers. Federal public health leadership has explicitly framed health misinformation as a serious threat to public trust and safety. Meanwhile, public confidence in scientific institutions remains substantial but uneven and polarized.

In the exam room, this translates into new, largely invisible labor. Physicians are no longer only clinicians; they are also epistemic guides, sorting claims, debunking narratives, repairing trust, and competing with algorithmically amplified certainty. This too consumes time and energy.

Ergo

Taken together, this is no longer a story about one physician choosing urgent care over private practice. It is a story about system design: widespread burnout, consolidated autonomy, insurance rules that convert care into bureaucracy, accelerating demographic demand, and a healthcare ecosystem that destabilizes mutual trust. Given this milieu, I worry about my other colleagues and wonder what, if anything, might help make the practice of medicine more sustainable so that fewer amazing doctors take the unhappy exit as my friend did.

So what can be done?

My friend’s revelation forced me to examine my own work. Am I fulfilled? Does private practice psychiatry afford me the room to explore my diverse interests? Thank goodness, my answer is yes. I am grateful to work with incredibly wise and interesting patients who fill my heart and mind, and I have intentionally cultivated a professional milieu that prioritizes my eudaimonia. I have been fortunate to preserve time for deep patient engagement while also exploring philosophy, policy, and research. But that combination is increasingly rare.

The practice of medicine, once deeply relational, has become more transactional and procedural. My colleague’s story reflects that broader problem. I have an idea about how to address this. Before getting there, however, we should pause and consider what this looks like from the patient’s perspective.

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My dearest wife, my light, my heart.

I am so sorry that I’m asking you to do this again.

I know that change is hard.

That you are frustrated with me for leaving Ur in the first place.

My uncle is so charismatic he convinced me to go with him.

I had no idea that we’d end up here, in this place, now.

That doesn’t change things, though, at least as it relates to…

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You fucking asshole.

I can’t believe that you’re pulling this shit again.

Didn’t we leave Ur twenty years ago to follow your dumbass of an uncle on one of his wild goose chases?

Oh sure, he said a voice told him to leave and he’d be famous.

How did that turn out?

Here we are, you idiot!

Are you famous?

Will anyone ever remember your name?

We’re here and now you…

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This is how I chose to respond to their prompt.

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At sunrise
Grind, bloom, pour, swirl, rinse
Plum sweetness

A first sip
Glory onto all
Steam rises

The last sip
My eyes sweep downward
Tomorrow

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I was eleven.

I didn’t know what was happening at first. I knew I didn’t feel good. I was hot like I had been wrapped in ten wool blankets and sat in a hot bath in the middle of the street on the hottest day of summer.

My mother noticed something was wrong; she had a knack for that. She pressed the back of her hand against my forehead, and she smiled. She knew what was coming. If she was afraid, she surely didn’t show it.

“You’ll stay home today,” she said. “We’ll have some quiet.”

By the afternoon, a rash appeared: red blossomed across my chest and arms, angry and unmistakable. I remembered that a few of my classmates got sick with something a few weeks before and had been missing from school, but as the rash spread, the name they called it floated somewhere beyond the edge of my mind. No one in our house said it aloud. It was obvious to anyone who had lived through such things. Measles, the world would have said. But my parents did not.

“You are not sick,” my mother said with conviction. “What you’ve got is not the truth of you.”

As the house grew still, word was sent for prayer. A Christian Science practitioner arrived that evening, a woman trained in the methods taught by Mary Baker Eddy herself. She did not ask how long the fever had lasted or whether the rash itched or burned, as the doctors later did. She sat beside the bed and spoke quietly about God as infinite Love, about man as His image and likeness, untouched by decay or corruption.

The fever broke. The rash faded. I returned, thinner but steady, to my ordinary life for a moment.

And then it returned.

This time it felt like it came more fiercely. The heat lingered, and my skin became raw in places, as though my body was shrieking at itself. I have a distant memory of my parents’ faces, already exhausted from my first bout, now twisted twice as tight in determination not to let doubt win. This, they understood, was the moment when the temptation of the devil most often crept in: when illness seemed to persist, when appearances required one to believe that matter, not God, had authority after all.

There was a frank discussion, quiet and serious. It was decided that a physician would be consulted. My parents’ fear had not yet been fully overcome; my faith had not failed.

The doctor was kind. He tried many remedies. Ointments, poultices, rest. Nurses came and went. At one point, I heard the word “dangerous” spoken in the hall. But I bound myself in His Love. Later still, I remember hearing that if the condition worsened, drastic measures might be needed to preserve my life. I did not doubt.

Through all of it, my suffering was real. Days blurred into weeks, and though I was kept my sleep came only fitfully. My mother continued to read passages from the bible affirming that God’s creation could not include disease, and that suffering was not ultimate, even if it felt that way.

Eventually, the physicians admitted they could do no more.

That was the day the true miracle happened: it was only then that my family truly embraced Christian Science. Whatever doubt they once had departed when the last doctor left. The practitioner came daily. Members of our church prayed with constancy, insisting on the unreality of my affliction. I knew then as much as I know now that God’s creation could not include disease.

Within a few weeks, something began to shift as clearly as the dawn.

My ruin receded, my strength returned, and I finally slept soundly throughout the night. I stood, I walked, I even smiled. No one made a declaration of cure. We recognized with perfect certainty that the illness had never been what it appeared to be.

My parents were grateful because they knew why I was well. The healing was understood as evidence: proof that God, as divine Principle, governed reality; that their fear and doubt, once dissolved and bound up with the lord, could no longer masquerade as disease.

I heard others speak of their moments of realization when they or their children were restored to full health in the moment of true faith. When fear was extinguished, so was the fever; women whose bodies bore children without pain once suffering was recognized as illusion rather than necessity. These stories served as confirmations that the suffering of illness is a trial given by the Lord to burn out the doubt of His divine providence. My restoration happened only when I, and my parents, saw the true nature of things:

That spirit, not matter, was real.
That His Love, not law, governed.
That illness was not an enemy to be battled, but an error to be undone.

And that we are all, truly, in God’s hands.

When I returned to school, my classmates asked where I had been, why no doctor had saved me, and how close I had come to dying. I did not yet have the language to answer them.

All I knew was this: when my body seemed to fail me, my family, my community, and my soul did not turn against it. They turned toward God. Once they did, the rest followed.

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To that end, if you might let me know if there’s a topic you’d like me to cover. Perhaps a more in-depth discussion about what I’ve writ…

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Yanna Yang and Rainbow-Colored Vomit

During my time as a program coordinator at Manakai O’ Malama, a complementary and alternative medicine (CAM - this is now called “integrative medicine”) clinic on the island of Oahu, I became friends with Dr. Yanna Yang, a gifted practitioner of Traditional Chinese Medicine (TCM). Given my interest in all things CAM, I spent as much time with her as possible, hoping that she might teach me how to place needles or use traditional herbal medicines so that I could, one day, use these tools in my own clinical practice. When she offered to give me a treatment, I took a breath, drummed up the courage to face my decades-old fear of needles, and said yes. I was young, naive, and convinced I had nothing objectively “wrong” with me, at least by biomedical standards, but curiosity has its own momentum.

If you’ve never been evaluated by an acupuncturist, or by someone practicing outside the Western medical frame, prepare for a radically different kind of assessment. Dr. Yang asked about my digestion and stool, my sleep, my preferences for flavors (sweet, sour, salty, spicy), and then spent several long minutes examining my tongue. She also took my pulse, but not in the way I’d learned as a doctor-in-training. Her three fingers moved across my wrist with subtle shifts in pressure and position, more like a musician finding the right fingering for a chord than a physician counting beats.

After a long silence, she shook her head with concern and said, gravely, “Ben, you have heart-yin deficiency.”

My mind filled with questions. What is yin? What does it mean for the heart to be deficient? Why did she look so serious?

Before I had time to distill my swirling thoughts into questions, she brought me to the treatment room and asked me to remove my shirt and roll up my pant legs. Within minutes, she painlessly placed more than two dozen needles along my legs and back, and one at the crown of my head. She positioned a heat lamp over me (I later learned she would have preferred moxibustion) and left me alone in the treatment room, my mind full of questions and fears.

Lying there, something unexpected happened. The usual internal chatter quieted, and my body began to pulse with a steady, spacious rhythm. Then, vividly, absurdly, beautifully, it felt as though my heart opened like a plumeria flower, and a stream of rainbow-colored vomit poured out of it into the endless well of the universe beneath the treatment table.

That may be the strangest sentence I’ve ever written. I’m not saying that’s what happened, but as an inner image, it landed with the force of revelation. Something inside me was releasing. Something stuck was moving. Something overguarded was pouring, heart beat after heart beat, into the welcoming arms of eternity.

When Dr. Yang returned 45 minutes later and removed the needles, my pillow was soaked with tears. I felt overwhelmed with gratitude and tenderness, so much so that I had to actively restrain myself from hugging her.

In the days and weeks that followed, as I received more acupuncture and tried herbal formulas, I asked her to explain what she meant by “heart-yin deficiency.” Her explanation became, for me, a doorway into an ancient (and modern) way of understanding illness and healing: the idea that a human being is a living balance of fundamental elements.

The Logic of the Elements: How Balance Becomes Health

As foreign as this may sound at first, this model of reality reflects one of the oldest and most widespread ontologies in human history: the idea that reality is organized by a small number of foundational “elements” or “essences,” each with characteristic qualities.

Across cultures, these essences are described differently, but the logic is strikingly consistent:

• The essences have recognizable tendencies (hot/cold, wet/dry, heavy/light, expansive/contracting).

• They interact according to intelligible rules (some combinations amplify, others neutralize; others overwhelm).

• These fundamental essences are not static, but operate in a “dynamic equilibrium,” driving the cycles of the world (e.g., seasons, sunrise, and sunset), and serving as the foundation of creative and deconstructive forces.

• Natural disasters on the macro-scale, and illness on the human-scale, reflect disequilibrium among one or more essences.

More specifically, in an essence-based ontology, illness is a significant imbalance of vital forces within an individual. This could originate from a lack of alignment between the individual’s essential constitution and their behaviors (a fire-aligned person could eat too much water-aligned food), or from an extreme unidirectional imbalance (a person with heart-yin deficiency could engage in behaviors that further deplete their heart-yin). Healing, therefore, is oriented toward identifying innate constitutional orientations and restoring natural, harmonious balance through adjusting inputs (food, sleep, activity, social rhythm), working with environmental cycles (season, climate, light/dark), using interventions that carry recognizable qualities (warming, cooling, drying, moistening, stimulating, calming), restoring movement where there is stagnation, and restoring containment where there is excess.

In this framework, a fever can be understood as “too much heat,” and the clinical question becomes: is this heat useful, dangerous, compensatory, or misdirected? Depending on the answer to that question, the cure could either be to support the fever (providing blankets or hot beverages), to remove the source of the heat (“starve a fever, feed a cold”), or to redirect the heat of the fever by inducing sweating or providing cooling foods to absorb and contain it.

Before you reject this theory of healing as antiquated, consider how ubiquitous this way of thinking about health and illness is in our daily lives. We unconsciously use language that conveys a belief in elemental qualities: “I’m burned out,” “I need to chill,” “I need grounding,” or “my head is in the clouds.” If you’ve ever responded to a cold with hot soup, a heating blanket, and rest, you’ve performed an intuitive version of elemental medicine, whether or not you call it that.

The World of Essences

An essence-based ontology, and the theories of healing that flow from it, may be the most common and enduring medical model in human history. It remains a living tradition across Asia in the form of Traditional Chinese Medicine and Ayurveda, and it persists in the West through the long shadow of Greco-Roman humoral medicine. In the next section, I offer a brief, necessarily incomplete, and grossly imperfect overview of these three frameworks as a way of making their shared pattern-language easier to see.

Traditional Chinese Medicine: A Web without a Weaver

In TCM, health is often described in terms of patterns rather than discrete diseases. Yin and yang are the primary polarities: cool/warm, inward/outward, receptive/active, and they organize the movement of qi, a term that can be translated as “vital energy,” though in practice it functions more like a conceptual bridge between physiology, experience, and environment.

From yin–yang dynamics, classical Chinese medicine describes five “elements”: wood, fire, earth, metal, and water. These elements correspond to organ systems and to cycles of generation and restraint. Think, “how the body moves, transforms, and stays coherent over time” rather than, “what the body is made of.”

So when Dr. Yang diagnosed me with a “heart-yin deficiency,” she wasn’t saying my cardiac muscles were failing. Instead, she was describing a pattern of too little of the “cooling, nourishing, settling” quality associated with the heart system in that tradition. This was often linked (in modern clinical translations) to insomnia, restlessness, emotional agitation, dryness, or a sense of being internally overheated or unmoored.

Even if you don’t accept the metaphysics, it’s hard not to notice the practical implication: this is a diagnostic language oriented toward balance and relationship, rather than dysfunction or malfunction.

Ayurveda

In Ayurveda, health is also described in terms of the characteristic ways a person’s system tends to organize itself over time. The basic “grammar” of Ayurvedic physiology is the interplay of three doshas—vata, pitta, and kapha—which one can think of as governing principles of movement, transformation, and structure. Each dosha has a recognizable texture and momentum in lived experience: some people run light, fast, variable, and easily become unmoored; others run hot, sharp, intense, and easily become inflamed; others run cool, heavy, steady, and easily become congested or slowed.

Those doshas are traditionally derived from the five great elements (pañcamahābhūta): space, air, fire, water, and earth. But as with TCM’s “elements,” the point is less that a human being is literally made of these substances and more that these categories describe tendencies, or the felt and observable qualities of a system. Vata is often associated with space and air (light, dry, mobile, irregular); pitta with fire and a bit of water (steamy, hot, penetrating, metabolic, clarifying); kapha with water and earth (heavy, cohesive, lubricating, stabilizing). In other words, the elements become a way of speaking about the style of balance or imbalance.

Ayurvedic diagnosis is a kind of pattern recognition: What is this person’s underlying constitution (prakriti)? What has shifted out of proportion right now (vikriti)? What qualities are in excess (i.e., heat, dryness, heaviness, instability), and what qualities have become deficient? Treatment aims to restore proportion by working with opposites: cooling what is overheated, moistening what is too dry, mobilizing what is stagnant, and stabilizing what is too variable. Diet, sleep, daily routine, herbs, bodywork, breath practices, and seasonal adjustments are all used as “quality-based” interventions, or methods of reintroducing the missing qualities and tempering the ones that have become excessive.

Greek and Roman Lineage: Elements and Humors

In the Western canon, the best-known form of this ontology appears in classical Greek thought. The four elements—earth, water, air, and fire—are often associated with Empedocles and later developed by Plato and Aristotle. Aristotle also emphasized a fifth “heavenly” substance, aether (later called “quintessence”), as the material of the celestial realm.

In Greco-Roman medicine, this elemental worldview expressed itself through the theory of the four humors (classically associated with Hippocratic texts and later systematized by Galen): blood, phlegm, yellow bile, and black bile. These were not, as they seem, bodily fluids; instead, they were explanatory principles linking constitution, temperament, seasonality, and illness. A “phlegmatic” person, for example, was understood as someone whose pattern of being leaned cold, slow, and heavy, or someone whom we might today see as persistently fatigued, with a low or depressed mood and sluggishness. By contrast, a “sanguine” person, someone like Matteo (see my last post), was described as warmer, faster, and more gregarious.

Under this framework, diagnosis meant naming a pattern of imbalance, and treatment meant restoring proportion through diet, sleep, movement, social rhythm, herbs, heat/cold, and (sometimes disastrously) practices like bloodletting.

The Legacy of the Ontology of Essences

I often see the imprint of this essence-based ontology in my clinical work. Sometimes it appears directly in patients who have worked with acupuncturists, Ayurvedic clinicians, or homeopaths. More often, it shows up indirectly, embedded in the everyday language people use to describe their inner lives: feeling “depleted,” “overheated,” “stuck,” or in need of “grounding.” In that sense, the model has never been fully replaced by modern biomedical approaches or sensibilities.

Even within conventional medicine, we still rely on its logic more than we’d like to admit. We talk about “inflammation” as though it were a single substance rather than a family of mechanisms; we prescribe “cooling” or “warming” behaviors in the form of rest, hydration, light exposure, exercise, and dietary changes; we intuitively track states of excess and deficiency long before we can name a diagnosis. The language is different, and the explanatory scaffolding has shifted, but the underlying impulse remains the same: to understand suffering as an imbalance of forces within a living system, and to restore coherence by adjusting the qualities of what we take in and how we live.

Next week, I’ll dive into the ontology of spirit. Have a wonderful week!

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And when I feel it,
all I can do is stop, because it just takes me and holds me
so tight—
in a vice between utter joy and
absolute longing.
That swelling in your throat that pains your heart more than your body.
That silly, but overwhelmingly
emotional searching for a world you once knew
but
can never really know again.
Though a homesickness of sorts, this emotio…

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