A look into the world of holistic psychiatry with Dr Ellen Vora

A look into the world of holistic psychiatry with Dr Ellen Vora

Our world is in the middle of a mental health epidemic. As we move into the future, more people are looking for holistic approaches to living and the health issues they face, so it's no surprise that people needing mental health care are opting for holistic psychiatry and the incredible solutions it can provide. Someone who is really shining in this field and leading the way is Dr Ellen Vora.

Dr Vora is a Board-Certified Psychiatrist, acupuncturist, yoga teacher, and the author of her new book 'The Anatomy of Anxiety: Understanding and Overcoming the Body's Fear Response' - a practical, informative, and profoundly hopeful book that fully explains the origins of anxiety and offers a detailed road map for healing and growth.

Dr. Vora takes a functional medicine approach to mental health, considering the whole person and addressing the problem at the root rather than reflexively prescribing medication to suppress symptoms. Dr. Vora spoke to us about how our genes are only a small portion of what contributes to mental illness, shared her thoughts on prescribing pharmaceutical drugs, and makes the connection between underlying trauma's effects on our mental health and how we can start to heal.

What led you on the path of becoming a holistic psychiatrist?

I'm a cliche of the wellness world, but much like many other holistic practitioners, it was my own health struggles that revealed the shortcomings of our allopathic medical system. While I was a medical student, my health was falling apart. I had PCOS, acne, joint pains, ocular migraines, IBS, and the beginnings of an autoimmune disease. Every conventional intervention I tried came up short. I was learning how to get myself well in parallel with learning how to better help my patients thrive. Over time, I observed that taking a holistic approach was necessary to achieve balance and wellbeing. I learned this in my own body first, and then I learned this in supporting my patients on their healing journeys.

What exactly is holistic psychiatry? How is this approached differently than traditional psychiatry?

I was trained to think of mental health from the neck up. However, holistic psychiatry means that I instead examine the whole portrait of my patients' lives—from what they eat to how they sleep, to the quality of their relationships, to where they find meaning, purpose, and refuge in their lives. In doing so, I have found that the anxiety that plagues so many of us is increasingly caused by the habits that are now intrinsic to our modern lives, such as chronic sleep deprivation, poor nutrition, and even doom scrolling on social media late into the night, in addition to the estrangement from community that we're experiencing in modern life.

There's this idea that our mental health is a genetically determined chemical imbalance. How is this an old way of thinking about mental health?

Our genes have an impact on our brain chemistry, and our brain chemistry can impact our mood, but that is never the whole story. In fact, while brain chemistry and thought patterns do play a role in anxiety, I would argue that these are often "downstream" effects—meaning that frequently our brain chemistry changes as a result of an imbalance in the body. In other words, the root cause of much of our mental health struggles begins in the body, and if we want to address it effectively, it should be treated at the level of the body as well.

What are your thoughts on prescribing prescription medication, and do you feel it's really needed? 

I'm not dogmatically opposed to psychiatric medications. At times I prescribe them. They can be a lifesaving bridge to help someone climb out of a hole. My concerns with psych meds are as follows: we reach for them first when instead, we should first be attempting to identify the true root cause of mental health issues. Reaching for meds first assumes that mental health struggles are a lexapro-deficiency disorder, when in fact, much of the time mental health issues are the result of a state of physical imbalance, such as systemic inflammation, chronic sleep deprivation, hormonal imbalance, poorly managed autoimmune thyroid conditions, micronutrient deficiency, gut dysbiosis, and side effects from medications (such as exogenous hormones).

Mental health issues can also be the result of unmet needs--such as our fundamental human need for community or purpose. This doesn't even begin to address how much of the time, what we call mental health issues are simply a direct result of trauma. So, I look at these potential root causes first and do my best to work together with patients to address them. If this doesn't yield sufficient improvement in symptoms, it's nice to have medication as a backup option. But it's never the first tool I reach for, and I wish more psychiatrists would think more creatively and open-mindedly about other potential root causes of mental health issues first.

What role does unresolved trauma play in mental health issues?

It plays an immense role. Traumatic experiences are often stored in the body—as the psychiatrist and bestselling author Bessel van der Kolk, MD raised in his groundbreaking book The Body Keeps the Score—which then also reprograms the brain. When this occurs, the amygdala—that part of the limbic system responsible for our fear response—is left in a state of hyperarousal, creating disproportionate anxiety throughout life. Trauma—which can occur from a range of experiences, from sexual assault to combat to emotional deprivation from a parent—leaves the brain on high alert, even if the threat is no longer present. As such, the brain can misinterpret danger where there is none.

When a trauma occurs, our body goes through a significant fight, flight, or freeze response. If this stress cycle is not brought to completion, adrenaline can continue to flood the body, leaving us with an intense energy that needs to be discharged and a chronic state of hyperarousal, which can continue as long as the trauma is held in the body. It's as though the unmetabolized trauma is a key stuck in the ignition of your fight-or-flight response, keeping the engine idling. In that state, your unconscious is hypervigilant, forever surveying the landscape for threats. Thoughts and feelings are filtered through the fear-tinted lens of trauma. Interactions and sensations are perceived as more menacing than they actually are.

What are the first steps to healing trauma trapped in the body?

Trauma is held in the body, in the connective tissues and in the nerves and fibers of the nervous system, and therefore, talk therapy is limited in its usefulness. In fact, hashing and rehashing a trauma verbally, even with a caring therapist, has the potential to be re-traumatizing. The best treatments for relinquishing long-held trauma—and finally releasing its ongoing stress cycle—are trauma-specific therapies.

These include: Eye Movement Desensitization and Reprocessing (EMDR), in which a patient closes their eyes and moves them rhythmically as a therapist talks them through their traumatic event (the mechanisms at play here are still not entirely understood, but clinical trials conducted over the last several decades have proven it to be successful); something called DNRS, which stands for Dynamic Neural Retraining System, aimed at reprogramming the limbic system; and Somatic Experiencing therapy, which uses mind-body exercises to release trauma. These therapies take into account the physical need for moving the stuck energy of the stress cycle and accessing trauma at the level of the limbic system and the body, making them much better suited to trauma recovery than traditional talk therapy. Trauma-focused therapy can also be especially helpful in allowing the brain to register the message: that was then, this is now;you are safe.

Explain the role of psychedelics, and how they can be used for those with anxiety?

If dreams are "the royal road to the unconscious," as Sigmund Freud once stated—then psychedelics are the divine hotline. A patient once described her experience on psilocybin—the psychoactive component of mushrooms belonging to the Psilocybe genus—as feeling "as if I was sitting in my therapist's office, delving deeper and deeper, only to look up and discover the psychoanalyst was me." I, myself, have experienced psychedelic ceremonies as more like having God as my therapist.

A number of my patients who have immense difficulty addressing their true anxiety or finding peace have ultimately found a path forward with psychedelics; they have discovered that taking these medicines not only finally allowed them to confront deep-seated fears, but also to negotiate a truce with them, creating an enduring sense of calm.

There's reason to hope that psychedelic treatments could prove to be as major an innovation in psychiatry as the advent of SSRIs in the late 1980s. The field of psychiatry is currently in crisis. The SSRIs frequently prescribed for anxiety and depression are not as effective as we once believed. They can carry a heavy burden of side effects, and, as we've discussed, it can be difficult, even excruciating, to discontinue them.

It's early days yet, but some very interesting recent research suggests potentially groundbreaking mental health treatments involving psilocybin, ketamine, MDMA (3,4-methylenedioxymethamphetamine, also known as ecstasy), and other psychedelics, which have been shown to help such debilitating disorders as anxiety, PTSD, depression, and opiate addiction. And unlike conventional medications, which create dependence over time, psychedelics, for many, eliminate the need for themselves.

I believe these substances will increasingly become understood as revolutionary approaches for patients with intractable mental health issues. I'm glad we are headed in a direction that will make these treatments accessible to many more people, offering a chance at transformational healing. I also hope that, as psychedelics become increasingly mainstream and overlap with the pharmaceutical industry and the medical setting, we can nurture a sense of honor and respect for them. As traditional cultures have known for several centuries, these medicines are sacred and, as such, should be approached with reverence and care.

With the critical caveats that psychedelic treatments are not safe for everyone—they are relatively contraindicated for anyone with a personal or family history of bipolar disorder, schizophrenia, or other psychotic disorders; more research is needed, and I do not recommend taking these drugs outside of a safe, facilitated setting or without support to integrate the experience––I do believe we have the neurobiological, psychological, and physiological reasons to be hopeful, as well as to fund more research.

Psychedelic medicines improve the functioning of our brain chemistry in a variety of ways. They enhance serotonergic signaling at what are called the 5-HT2A receptors in the brain in a way that seems to be lasting and effective, without being numbing or creating a withdrawal state. This is what researchers believe accounts, at least in part, for the enduring antidepressant and anti-anxiety effect of a single psilocybin ceremony.

Psychedelics also increase the secretion of a very important signaling molecule called BDNF or brain-derived neurotrophic factor, which promotes neurogenesis and neuroplasticity. Translation: BDNF helps the brain grow, change, and adapt; so, if you're stuck, as Ethan was, BDNF helps you get unstuck. This discovery has exciting therapeutic implications for treating entrenched psychological patterns like PTSD, ruminative depression, and addiction. Certain psychedelics are also anti-inflammatory—which is useful because inflammation is a common contributor to anxiety and depression.

Another line of research has explored the effects of these medicines on the default-mode network (DMN)—composed, in part, of the aforementioned medial prefrontal cortex (mPFC) and the posterior cingulate cortex (PCC) and is the part of our brain responsible for our sense of ourselves as separate from others—suggesting treatment possibilities for people experiencing alienation, loneliness, and trauma, as well as the anxiety that comes alongside these. Viewing ourselves as individuals navigating our own challenges has served the human race to a certain extent evolutionarily, allowing us to learn from our mistakes, anticipate potential negative outcomes, and fight for our own survival. Yet, a temporarily quiet DMN––which psychedelics help us achieve—grants us a reprieve from future-tripping and dwelling on the past. And perhaps we benefit collectively when more of us spend time with a dialed-down DMN, allowing us to explore a feeling of interconnectedness with our fellow beings and our planet while rethinking that narrow definition of ourselves as separate.

Finally, psychedelic experiences can more directly help people discharge stress, allowing them to complete the stress cycle through shaking and sounding (e.g, chanting)—actions that are common in the psychedelic experience but typically inaccessible in our relatively more inhibited daily lives. In less clinical terms—and, frankly, from my own experience taking ayahuasca in Brazil (where it is legal) and psilocybin in a formal setting with a facilitator—for a few hours during the psychedelic ceremony, you get a glimpse of another reality, which can take the pressure off of this one. It's humbling and freeing to see beyond logic that there is more to life than our material existence—and that perhaps it's not all up to us. You might begin to trust that something greater than what you could possibly comprehend is unfolding. "Psychedelics are much more than tools for healing trauma," as my friend and colleague Will Siu, MD, PhD, wisely remarked, "they are helping spirituality become palatable to a starving Western world."

Perhaps most critically, for some, psychedelics can decrease a fear of death—which sits at the very center of true anxiety. Several randomized controlled trials with longitudinal follow-ups, have shown psilocybin not only inspires spiritual revelations, reducing anxiety and depression, but it also allows people to overcome end of life anxiety. In 2011, for example, researchers at UCLA conducted a trial led by psychiatrist Charles Grob, with twelve terminal cancer patients experiencing anxiety, depression and existential dread.

Researchers found a significant reduction in anxiety and a reduction in fear of death among these patients after three months—and an improvement in mood for up to six months afterwards. This study was corroborated by a large randomized, double-blind study led by Roland Griffiths in 2016.

This brings to mind the so-called "mystical experience" hypothesis, which posits that when someone takes a psychedelic in a proper set and setting, they will reliably have a peak spiritual experience, typically feeling a sense of unity or a recognition of oneness with the world. And the degree to which someone has a mystical experience predicts positive therapeutic effects—that is, the mystical nature of the experience is proportional to the lasting benefits of the psychedelic (such as a decrease in depression). In other words, the more mystical the experience, the more effective the medicine. National Geographic host Jason Silva describes this phenomenon as "inverse PTSD"––an experience of such radiance, astonishment, and grace that it can transform a person's character structure in a similar way to trauma, but building toward openness and love rather than fear and mistrust. The mystical experience hypothesis suggests that the journey itself is what offers much of the benefit. There's a reason we call it a "trip"— psychedelic medicines guide us through a journey, and we learn and grow along the way. In the words of my friend, psychedelic researcher and psychology professor at Yale, Alexander Belser, PhD, the messy part of the trip is "a feature, not a bug." I tend to believe this is true not only with psychedelics, but also in life.