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Duncan McEwen, MD

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Durham, NC 27707
Telephone: (919) 810-3536

Untangling the Threads of Mental Health

Psychiatrist Duncan McEwen compares the complicated factors affecting mental health to a tangled skein of yarn. “Your genes certainly matter,” he says, “but they’re only one strand—and they only suggest a path in life, they don’t determine it.”.

Dr. McEwen

In the therapeutic model he uses, Dr. McEwen emphasizes the importance of teasing out biological, social, and psycho-logical threads. ““Because these variables interact, it’s sometimes not clear how to untangle the knot or how much weight there’s going to be to each strand,” he says. ‘For example, even if you’re a robust, healthy individual, with good genes and good psychological upbringing, if I put you in a dungeon long enough, I probably can break you down and get you depressed.’

“On the other hand, if you have a heavy load of genetic problems, you might not be able to respond to the opportunities life is giving you—even if you have all of the opportunities and advantages a person could wish for—because the biological dimension will weigh you down. So, it’s imperative that we consider all these variables—and their interactions—in forming both our impression and a treatment plan.”

A Balanced Approach to Psychiatry

The balance of how clinicians look at the different dimensions of functions has shifted over the years, Dr. McEwen observes. “When I started in the field in the early ’80s, there was an explosion in the introduction of new psychotropic medications—such as Prozac. And all of a sudden, psychiatry became medicalized and patients tended to become diagnoses and collections of symptoms—to the extent that the trend in psychiatry was to diminish patients being seen as persons. But people aren’t just a collection of symptoms, they’re human beings with stories that are often more important than their symptoms. Psychiatry was at risk of failing to recognize and address all the factors influencing its patients.

“Happily, we’re now moving back toward a more balanced approach—combining medication and psychotherapy,” he notes, “one that recognizes that genes and environment play fluid roles, not only by affecting patients’ health, but also in helping them heal.”

Medications do play an important role in Dr. McEwen’s practice, particularly for the acute symptoms that often bring patients in to see him. “Patients often initiate their treatment when something dramatic has happened,” he says. “Maybe a marriage has ended, or substance abuse may have escalated, or the patient notices they can no longer function at work because of anxiety or other symptoms. That’s when medications—which target paralyzing symptoms—can play a role in helping someone to heal.

“I’d compare doctors and their medication, to a team doctor or sports trainer wrapping an ankle in order to send an injured player back onto the playing field of life,” he says. “But treating the immediate injury is the first, not the last step. It’s often necessary to move beyond the short term. I’m a big believer in counseling and of the benefit patients can have by working with a life coach.”

The Role of Genes; the Influence of Environment

“There are a number of psychiatric conditions with genetic links,” notes Dr. McEwen. “These include autism, attention deficit disorder, depression, panic disorder, and schizophrenia. And recent advances in genetic testing—which make it possible to identify those links—will soon offer a really exciting opportunity to understand inherited traits and genetic propensities, and how they interact with social and psychological influences.”

But a note of caution is in order, he says. “With direct-to-consumer testing like 23andMe now broadly available, there’s a risk of overly simplistic interpretation of genetic data creating more confusion than benefit.

“For example, one of the things that’s interesting is that often the test will give you contradictory findings. You may have one set of genes suggesting a higher risk for a problem, and another set that appears to be protective for the same problem. The value of the information lies in the interpretation—and often the support of a professional—to help put it in context.”

Strengths and Weaknesses: Two-Sides of the Same Coin

“What I find most interesting about these genetic profiles is that they underscore the wonderful complexity of the human psyche,” observes Dr. McEwen. “You might argue that a person’s genes are destiny, that certain attributes are ingrained. On the other hand, when evaluating a person, we often find that one set of genetically determined traits that might be considered a weakness are counterbalanced by others that can be exploited as strengths.

“It’s important to appreciate that even traits that initially appear as weaknesses can sometimes be harnessed and turned into strengths. That’s something I’ve seen over and over in my practice.  If one is aware of a challenging attribute, one can pay more attention to making sure it doesn’t have negative implications in real life.”

For example, he says, “a person with autism may not have natural social intelligence. But they can develop those skills if they’re aware of the genetic vulnerability. They may learn them in more of a cookbook fashion than by intuition, but they can still learn and develop those skills.

“And just as important, the individual with autism can understand and capitalize on inborn strengths. He may have, for example, intellectual curiosity and talent in fields such as engineering or mathematics. I have also found that people in the autism spectrum often have a high emotional quotient for loyalty and adherence to norms.

“My role in guiding treatment, is to be aware of both strengths and weaknesses,” says Dr. McEwen. “The goal is to minimize the damage of the weaknesses and take advantage of the strengths.’

Capitalizing on Strengths

Many times, people don’t recognize the strengths that come so naturally to them, and hence, they take them for granted. “But the bottom line is we’re trying to ignite some kind of spark in people,” Dr. McEwen explains. “So, helping people recognize their talents is a way of igniting a spark that can help the patient feel a sense of self-worth.”

Strengths, notes Dr. McEwen, are sometimes found in unlikely places. “For example, I find that anger is a potential strength. Anger is raw energy; you might say that, in some regards, it is like fire. You can burn a house down with fire, but you can also fuel the cylinders in a car and do very constructive things with it. When anger is harnessed in a positive way it turns into assertiveness.

Dr. McEwen recalls a patient, a young man with major depressive disorder, with whom he was discussing a safety plan to deal with suicidal impulses. ‘When we were reviewing whether he needed to remove guns from the house he said he had asked his wife to hide his baseball bat. I was curious and had to ask how he felt a baseball bat could put him at risk of self-harm. He said, ‘Oh it’s not putting me at risk, but I’ve had a tendency to smash property with it.’

“Our work together helped him acknowledge this, which had been relatively hidden. He came to recognize that his depression was in part a cover for a hopeless feeling of frustration over things he hadn’t been able to cope with. The insight freed him to deal more directly with his anger and find ways to safely express and address it.”

Dr. McEwen derives much joy in helping people identify their strengths and understand what makes them special. “When a person identifies his strengths and tames his weaknesses, he is on a path to finding a new exuberance for life” he says. “What’s really fun for me is discovering the poetry of another human being and helping him weave it into the narrative of his life.”