In today’s fast-paced, ever-expanding psychiatric community, the value placed on speed, scale, efficiency, effectiveness, and economy borders on the excessive. This implicit in the modern healthcare paradigm is the belief that “fast is better.” Shorter visits, faster diagnoses, simplified procedures, and scalable solutions are considered unqualified positives. Perhaps no discipline has ratified this tenet with the fervor of psychiatry, which is now being asked to meet an unprecedented level of demand in a context marked by a reduced workforce, an ever-expanding nosology, and an ever-more pressing institutional imperative.
However, the one field of medicine that resists acceleration without consequence is psychiatry—and perhaps no other field of medicine resists. Minds do not develop at a predictable rate. Meaning cannot be triaged. There is no urgency to insight that suggests a correlation between the rate of development and the end result. The consequences of bad psychiatric judgment often become apparent only after time has passed.
It is against this background that Myleme Ojinga Harrison, MD, board-certified psychiatrist and President of The Carter Clinic, P.A., and whose approach is typified in his understanding of his own career and professional philosophy, embodies an intention to reject motion in favor of progress, to ensure that it is not speed one is going for but rather progress, and to see beyond specialization and innovation to make an impact based on discernment—something that Harrison has done after practicing for almost three decades in Raleigh, Fayetteville, and Smithfield in North Carolina.
The Identity Crisis of Psychiatry
Contemporary psychiatry is faced with a dilemma. Never before have mental health been so well understood in public consciousness. Never before have treatment protocols been called on to operate like a factory. Screening tools, diagnostic grids, medication algorithms, and treatment protocols ensure efficiency and standardization. From an administrative perspective, this is sound. Variability is decreased, risk is minimized, and more patients can be cared for within a shorter period.
Furthermore, in prioritizing throughput, the field of psychiatry risks discarding its very essence within the realm of knowledge itself. Symptoms are isolated from narratives. A diagnosis is set in stone. A treatment response is reactive instead of interpretive. What was once complexity is now something to be managed rather than comprehended.
Much of Harrison’s career has been an argument against this paradigm shift. ‘‘The practice of psychiatry is not about filling slots,’’ he has said on various occasions. ‘‘It’s about understanding trajectories.’’ The choice of the word ‘‘trajectory’’ is revealing. It has overtones of temporal sequence and direction.
“Train for Integration, Not Reduction”
Harrison’s attitude towards discernment developed quite early within his medical training at Duke University’s Internal Medicine and Psychiatry Residency Program. His training had a dual track that emphasized the unity between physical and mental wellness—not as a tenet, but as a reality.
Signals, not instructions, are symptoms in such a model. Mood disturbance could be a manifestation of endocrine problems, pharmacological reactions, disrupted sleep, trauma, and social factors. Psychotic symptoms might occur in a process spanning years, with alterations in meaning with a shifting context. There is no certainty in diagnosis. Humility is necessary.
It’s been noted that this training provided Harrison with a resistance to reductionism. In other words, rather than focusing his attention with subspecialization, Harrison has chosen to work with breadth. Indeed, over the course of several decades, Harrison has been working with all levels of mental health issues, including anxiety disorders, ADHD, major depression, bipolar disorder, schizophrenia, developmental disorders, and substance use disorders that commonly co-occur
Real patients, Harrison has noted, ‘do not arrive sorted.’ They arrive complicated. And complication, for Harrison, is not the same thing as lack of efficiency; it is, instead, the stuff of psychiatry.
Discernment in Clinical Practice
Discernment is not a form of indecision. It is not a condition of therapeutic inertia. It is a skill for discriminating between, and judging proportionally, partial information. The field of psychiatry, where treatment can alter identity, cognition, and self-concept, is one where this skill is critical.
His method contrasts sharply with the culture that values all things instantaneous that exists today. In today’s culture, disease can be easily identified for purposes of prescription. Decisions to switch patients’ meds are reached instantly with only partial information. Progress is measured by the reduction of symptoms.
Conversely, at The Carter Clinic, the decisions for the patient revolve around a long-term perspective. The changes to the patient’s pharmacological therapy take into consideration the patient’s past experiences and long-term goals. The patient’s therapy is not kept separate and distinct but combined for the patient’s benefit. The approaches to therapy include CBT, DBT, Motivational Interviewing, and Psychoeducation.
The implication is that this kind of model takes time, needs coordination, as well as the ability to tolerate uncertain outcomes. It also needs leadership that will shield clinical thinking from compression.
Continuity as an Act of Responsibility
No concept is more underemphasized in contemporary mental health care systems than that of continuity of care. The entry programs of access initiatives are more concerned with speed of entry than relationship. Providers are changed. Care is discontinuous. Patients recount their stories, yet nobody is kept to follow the narrative.
For Harrison, continuity is not only operational, but also ethical. The knowledge that he brings to his work as a psychiatrist is cumulative. Every intervention sets the stage for the next. If care were not continuous, he believes that practitioners are left with snapshots rather than stories to respond to.
In the Carter Clinic, continuity is maintained wherever possible. Transitions are carefully managed when moving from one point of care to the next. Care and treatment trajectories are developed rather than restarted when patients change care providers or when they shift between levels of care and treatment—a process that slows down some processes but provides continuity and decreases unwarranted changes in
“Psychiatric care doesn’t reset to zero,” Harrison once declared. “Neither should responsibility.”
Leadership That Protects Thinking
And, of course, as the President of The Carter Clinic, which now has locations across a dozen sites in North Carolina, Harrison’s reach goes beyond individual patient interactions. It is organizational level decisions that influence the kind of psychiatry that is possible.
Under this management, cultural aspects within clinical practices are considered infrastructure. The following expectations exist:
- Patients are never reduced to diagnoses.
- Practice is based on evidence but does not substitute for judgment.
- It is common for interdisciplinary work to be in a forward-looking marketplace with a focus on growth, short-term performance.
In a time when clinicians are often under pressure to hurry, it offers an opportunity to think. It suggests that thinking is not inefficient, but rather a protection mechanism.
“Culture sets the standards for whether or not healthcare professionals are permitted to be thoughtful,” observes a consultant for healthcare organizations. And it is thoughtfulness that keeps a patient from being harmed in ways that will never be measured by any data dashboard.
Context is the Clinical Framework
Through his work in such vastly different areas as Raleigh, Smithfield, and Fayetteville, Harrison has reinforced his convictions that psychiatric symptoms cannot be separated from context.
Patients do not appear in a vacuum. There is a cultural expression of distress. Geographic availability affects treatment experiences. Military groups have unique patterns of trauma, reintegration stressors, and family disruptions.
Contextual literacy is not something that Harrison views as supplementary or background information that is unrelated to his work with clients. Contextual literacy shapes symptom interpretation and treatment responses. Harrison’s work becomes focused on psychoeducation rather than its position on the periphery. Patients and family members are encouraged to be knowledgeable about diagnoses and treatment approaches as well as outcomes that might be expected
“When people understand what’s happening,” Harrison has said, “they interact differently. Confusion erodes care.”
Technology as Tool, Not Authority
It’s not that Harrison is against innovation. Telepsychiatry has increased the reach, and electronic health records help with continuity. Symptom tracking could be a helpful indicator.
What he rejects is the surrender of judgment to technology. Algorithms can identify risk, but they cannot infer meaning. Scales can measure distress, but they cannot contextualize distress within a life story.
“Data doesn’t carry responsibility,” Harrison said once. “Clinicians do.”
Technology, for him, needs to aid clinical thinking, not replace it. When systems began to prescribe the roles of responsibility became unclear.
The Cost of Getting It Wrong
“Mental health mistakes tend not to make their presence known loudly. Instead, they tend to go about their work quietly, through unnecessary drug exposure, premature closing of the diagnosis, reduced self-concept, or wasted years.”
A long-term approach is evident in Harrison’s career. Harrison approaches psychiatric decisions as commitments, not experiments. Each decision is taken with the end in mind.
Stewardship is not conservatism, nor is it passivity—it is responsibility over a period of time.
A Counterexample Worth Preserving
The more that mental health systems are under pressure and strain in meeting demand, the more likely it is that these pressures will be met with simplified answers. Rapid answers will be rewarded. Complex answers will be considered luxuries. However, it is not possible to strip back the work of psychiatry without its core being lost.
Dr. Myleme Ojinga Harrison counterposes: “Where there is a need for innovation and development, there must be restraint. A model of care that balances access and sophistication, restraint and innovation, growth and ethics is required.”
“Science will keep changing,” he said. “But the impact of what we decide won’t go away just because we move on.” In the healthcare culture characterized by the dynamics of velocity, this might be the most necessary reminder for the field of psychiatry. “Depth is not inefficiency,” says Ruhl and Furtholt in *Time and Space in Gestalt Theory* (1961). “If the discipline of psychiatry is to maintain its integrity into the future, this will not only require new technologies and greater access, but also individuals who are prepared to ensure a space exists to think.
Dr. Harrison’s career is a testament that such measures are still achievable—and still required.
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