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Life transitions are sprinkled with possibility. They invite adventure and hope. They can also force us to look inward, to reevaluate our life choices. They can beget sadness and regret, a mourning over the passage of time.
There’s nothing like kids getting older to remind us how it goes so fast.
Mary Louise Kelly writes out these very issues in her memoir It. Goes. So. Fast. It is a heartfelt chronicle of her eldest child’s final year at home, the death of her father, and other curve-balls in her life that forced her to reckon with her evolving roles as a parent, mother, daughter and wife. On this very special episode of Beyond the Prescription, Mary Louise describes the emotional and physical manifestations of grief, the bittersweet moment of sending a child to college, and the heartbreak of losing a parent and ending a marriage.
It turns out that even a woman who “has it all” isn’t immune to feelings of regret and sadness over the passage of time. Mary Louise’s authentic voice provides reassurance and hope that we are all caregivers at heart, doing the best we can with the time we are given.
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ICYMI 👉
* 4 Steps Toward Reclaiming Your Health
* It’s Okay to Not Be Okay
* How to Care For Your Body with Kindness & Respect
A note to paid subscribers: Join me for our next Zoom hangout on Tuesday, Feb 6 at 8:30 pm ET. The topic: Reclaiming Your Health in 2024. Bring your questions! Click here to register. 🎉
In a special video episode of today’s newsletter, my friend Shira Doron, MD, and I discuss the state of COVID—new variants, testing, treatment, boosters, and long COVID.
Shira is the Hospital Epidemiologist at Tufts Medical Center, an infectious diseases doctor, and Professor of Medicine at Tufts School of Medicine. She is a nationally recognized expert in antimicrobial stewardship and infection control. During the COVID-19 pandemic, she played a key role in helping the general public separate fact from fiction.
I hope you take a listen above!
In addition, here is Dr. Doron’s take on the current state of COVID & respiratory viruses in the U.S.:
Respiratory viral season is upon us. It’s likely that you know several people who are sick right now. These days, it can be hard to figure out how worried to be. Is this a “normal” flu season? Is COVID-19 “surging”? The media is paying more attention to respiratory infections than they did before the pandemic, and the headlines are often designed to garner clicks, which is to say they are sensationalist. Let’s cut through the hype.
Here are a few things to know:
Current state
There are many respiratory viruses circulating right now, most of which are always more prevalent in the winter. You cannot tell the difference between them without a test. Health authorities track a metric called “ILI” which stands for “influenza-like illness.” This metric encompasses all of the respiratory viruses including but not limited to COVID-19, influenza (“flu”) and COVID-19. Right now, where you live determines how much ILI you are seeing.
source: CDC.gov
Trends show that ILI peaked in the last week of 2023 and is coming down. The peak this season was lower than the year before, and comparable to the year before the pandemic, despite the fact that we have a new virus in the mix. In other words, this is a “normal” respiratory virus season in terms of severity.
This is an ad-free, reader-supported newsletter. Consider supporting this work with a paid subscription!
Testing and treatment
Health authorities still recommend that everyone test themselves for COVID-19 even if they have mild symptoms. That’s because everyone is still advised to stay home for 5 days if they have COVID-19 infection (plus another 5 days of mask wearing). Testing is especially important for people with risk factors for progression to severe disease (such as those over 65 years of age, who have multiple medical problems, are immunosuppressed, or are pregnant), because there are highly effective antivirals like Paxlovid for those who qualify. You should be aware that, while the accuracy of home tests hasn’t changed, widespread population immunity means that the levels of virus in your nose might not reach the detectable threshold until later in your illness, as late as day 4, so keep testing.
If you haven’t gotten the latest round of free tests from the government (announced November 20, 2023), they can be obtained at https://special.usps.com/testkits.
Testing for influenza is indicated if you are within 48 hours of symptom onset and have risk factors for severe disease. Antivirals for influenza can shorten the duration of symptoms. Talk to your doctor if you think you have the flu, which is characterized by sudden onset fever, body aches, fatigue and cough.
It is rarely necessary to test for other respiratory viruses, including RSV, because there are no available treatments for them.
Prevention
Updated annual vaccines are available for COVID-19 and influenza. For the first time, we now have immunizations for RSV too.
COVID-19 vaccines
No longer to be referred to as a “booster,” the 2023-2024 annual vaccine was reformulated to target more recently circulating strains of the virus. Everyone age 5 and older who is not moderately to severely immunocompromised is recommended to receive one annual dose. While vaccination is recommended for all individuals over the age of 6 months, those at highest risk stand to benefit the most. There are three options: the Pfizer vaccine, the Moderna vaccine, and the Novavax vaccine which is a good option for people who need or want an alternative to the mRNA vaccines.
RSV immunizations
Almost overnight, an entire arsenal of preventative strategies have been approved for RSV. They are:
* The Pfizer and GSK vaccines for adults over age 60—public health authorities recommend that people in this category discuss with their doctor whether the RSV vaccine is right for them.
* The Pfizer vaccine for pregnant women—all women should receive this vaccine if they are between weeks 32 and 36 before the end of January. This will protect their newborn baby from RSV infection. Fortunately, the RSV season is almost over for the year.
* The monoclonal antibody, Nirsevimab, for newborns—this preventative treatment has been in very short supply. Talk to your pediatrician if your baby’s mother did not receive the RSV vaccine during pregnancy.
Influenza
Annual flu vaccination is recommended for everyone over the age of 6 months. Patients age 65 and older should receive a high-dose, recombinant or adjuvanted vaccine for greater potency. People with egg allergy may now receive any vaccine (egg-based or non-egg-based) that is otherwise appropriate for their age and health status without the need to be vaccinated in a medical setting.
Other preventative measures
If you are high-risk or risk-averse, you may want to avoid crowded indoor spaces where the risk of respiratory virus transmission is higher. You can protect yourself with a well-fitting high-quality mask.
Maintaining your general health will go a long way to helping you successfully weather a respiratory infection, as it is inevitable that everyone will catch one at some point. Remember to eat well, get plenty of sleep, exercise, manage your stress, and optimize your underlying medical conditions like diabetes and high blood pressure.
-Shira Doron, MD
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You can also listen to this episode on Spotify!
The new weight loss drugs such as Ozempic are stunningly effective at helping patients lose weight and improve their metabolic health. Their existence also seems to have intensified polarizing rhetoric around weight, health and BMI.
On one end of the ideological spectrum, there is the “Healthy at Every Size” (HAES) movement that aims to decouple weight from worthiness—and argues that doctors who recommend weight loss to their patients with obesity do more harm by enabling body shaming without evidence to support the benefits of weight loss on health. On the other end of the spectrum is the camp that believes obesity is a result of poor health and life choices—and that patients with obesity should simply eat better and exercise more rather than succumb to the pharmaceutical industry’s latest fad.
Emily Osteris a Professor at Brown University, a best-selling author, and a leading voice in health economics. In her wildly popular newsletter, ParentData , she tackles pressing health issues of the day, helping people frame risk in order to make everyday decisions. Dr. Oster joins Dr. McBride on this week’s episode of Beyond the Prescription to discuss the data on BMI and health, and how to empower readers and listeners with nuanced information to be healthy, inside and out.
They review the data on the health benefits of exercise, independent of weight loss; the arbitrariness of BMI cut-offs; and the importance of focusing on health habits over a specific target weight. They agree that doctors do harm when they narrowly define health as a number on a scale—and the metabolic health involves addressing the medical, nutritional, behavioral or social-emotional elements of people’s health. As Dr. McBride says, “Sometimes that includes weight loss medication. Sometimes it’s a prescription to stop dieting and start eating lunch.”
The transcript of our conversation is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond the Prescription. Today we have an amazing guest joining us, my friend Dr. Emily Oster. Emily is a renowned economist, a bestselling author, and a professor at Brown University. Emily is one of the leading voices in health economics. Her superpower is applying data to some of society's thorniest health questions, including why people don't always make rational health decisions.
[00:01:30] In her wildly popular newsletter called Parent Data, Emily tackles pressing issues about pregnancy and parenting, helping decisions. I grabbed Emily today because I wanted to talk with her about her recent piece on body weight and health: What is the relationship between BMI and health? She pulled together a lot of data, and because weight is something I talk about with my patients every day, I thought I'd grab her for a chat. Emily, thank you so much for joining me today.
[00:02:03] Emily Oster: Thank you so much for having me. It is a delight as always to see you. It's such a treat.
[00:02:09] LM: Emily, you are no stranger to controversy. In fact, I was with you in the proverbial bunker during COVID, hiding from the haters who didn't like that you and I were trying to help message about risk. We were trying to help people better calibrate their degree of anxiety around COVID to their level of actual risk.
[00:02:31] By the way, I stand by everything I said and wrote. I hope you do too. And it was so fun to work with you then as it is now. So when I think about sensitive subjects, I think also about weight. And so, why did you want to write about weight? Is it just that you like putting your finger in the electrical socket? Or, did you have something to say?
[00:02:49] EO: So I've actually written about weight a bunch of times. So it is a topic that I work on in my academic work. So as a professor in economics, the work that I do is about health economics and statistical methods. And I actually work a lot on diet and dietary choices and why people make the dietary choices they do.
[00:03:07] And so it's not specifically about weight, but it really is about food. And so this is a kind of source of data that I think about a lot. And as a result, I've written about a lot in many different ways. And every time I come at this and I've come at it from all of the angles. So I wrote a piece once called what's the best diet?
[00:03:31] And it was just like the diet that you can stick to which is a sort of standard finding. But the frame was, you know, a lot of people are interested in diet. And when I write that, many people are very angry. They're sort of like, no diet works, we should never talk about dieting, is kind of what comes back.
[00:03:48] I did an interview with Virginia Sol Smith, who I really like, and we don't always agree but is just one of my favorite people to talk to. She always makes me think about her book Fat Talk, which is very much in the other direction, sort of very much in the space of, we should definitely not be talking about BMI, we should throw away our scales, all foods are neutral.
[00:04:10] And when I published that interview, I got it from the other side. I got the, you know, how could you possibly say this, cake and apple are not the same, like this is, this is insane. And I've written about Ozempic, so just anything, I mean, you know this—anytime you write about it in this space, there's really, really strong feelings from both sides.
[00:04:26] So this piece was trying, as I always do, more or less, sometimes more successfully than others, is to try to thread the needle and say, look, let’s look at the data and see between the view of BMI is completely meaningless and correlated with nothing, and the view that your BMI is completely deterministic of your health and that is the only information we should use.
[00:04:49] Where is the truth? And how can we use the data to get to that?
[00:04:52] LM: It is such a crucial question because everybody who's paying attention reads the headlines and understands from their doctor even that weight and weight management is good for your health. We have diet culture seeping into our pores. I mean, it's sort of in the air we breathe, everything you look at on the covers of magazines, on Instagram, and in doctor's offices is about weight, or it feels like it's about weight.
[00:05:20] I see people all the time who have avoided coming to see me, even if I've known them for decades, because they thought they would feel better about themselves, and I would feel more proud of them if they had just lost weight before they came in. And as I say to patients all the time, weight is one piece of a larger puzzle.
[00:05:36] It is not a reflection of your value, your worth. And it certainly doesn't tell us everything about your health. So I'd love to hear about your findings about the relationship between BMI and actual health.
[00:05:50] EO: In my mind, the most, the sort of most important thing to note here is that something can be correlated and can have some explanatory power and not be all of the explanatory power. So one version of this question is to say, on average, if your weight is higher, are you more likely to have other health conditions?
[00:06:13] And I should say, that's actually different from the question of whether weight causes other health conditions. But purely taking this from like a correlational standpoint, if you saw one piece of data about someone, you saw their BMI, would you learn anything about their health? And the answer is, yes. On average, there is a relationship, particularly at the upper end of BMI, between increasing BMI and worse health.
[00:06:41] And in particular, worse metabolic health. So things like, there's a strong correlation between high weight and diabetes. That's just true in the data. Now, those relationships... are there, but they're actually not as big, I think, as many people think. And that's sort of the other thing that comes out of this.
[00:06:58] And that, that has two parts. So one is actually, even to the extent that there's a positive relationship there, it doesn't show up until you start getting to sort of higher levels of BMI. So sometimes we talk, we talk about overweight being 25 BMI versus 24. Actually, the health differences between people with a BMI in the 25 to 30 versus 20 to 25, if anything, probably favor the 25 to 30, but you're certainly not seeing much in that range.
[00:07:30] As you get into a BMI of 35-40 you do see some of those, some of those correlations. But it's also true that in almost any health outcome you look at there is variation within a group and that's the thing I was sort of trying to illustrate in the piece is you look at something like diabetes or the distribution of blood pressure, like the distribution of blood pressure, it's shifted up for people who are higher BMI, but there's a lot of overlaps.
[00:07:56] Plenty of people with high blood pressure whose BMI is 19 and plenty of people with low blood pressure whose BMI is 38. And so that's the sense in which like this number Tells you maybe a little bit, but really not that much.
[00:08:12] LM: let's talk about what BMI is. BMI, I mean, you define it for us here, Emily.
[00:08:17] EO: BMI is a weight in kilograms divided by your height in meters squared. It's just a number.
[00:08:22] LM: So what you pointed out so beautifully in your piece is that medicine does this weird thing where we say that a normal BMI, body mass index, is between 20 and 24.9, and overweight is 25-29. 9
[00:08:37] EO: You guys love a sharp cutoff. It's your, it's your favorite. You love it.
[00:08:42] LM: I don't, but fine. The medical establishment loves these arbitrary cutoffs. There's nothing magical or particularly different between somebody who has a BMI of 24.9 and 25 and moreover, there are so many different elements that go into this whole person's health. That to call it a diagnosis point X and not a diagnosis at X minus .1 is ridiculous. So, you know, herein lies why we're here to talk about pulling back the curtain on what this actually means.
[00:09:18] EO: Right. And, and so I should say, like, you might wonder why have any cutoffs in this at all? I think the answer to that is that when people are describing, not even doctors, when population health scientists are describing characteristics of populations, it can sometimes be useful to define categories.
[00:09:40] So, you see this in weight, you also see it in something like low birth weight is another good example which has some cut-offs, right? So when we talk about baby weight, there's a number, 2,500 grams. And if a baby is below 2,500 grams, they're classified as low birth weight, and if they're above 2,500 grams, they're not.
[00:09:56] There's nothing special about 2,500 grams, obviously, but it’s helpful when we sort of describe a population. You want to say, does this, you know, is the low birth weight share in this population bigger than this population? We want to have a common language. And so saying, like, that's the cutoff we're going to use, so we have some number to compare, is helpful, it can be helpful. The same thing happens here. You want to describe characteristics of a population. I think the problem, and it actually shows up in the birth weight also, but the problem comes when we start, we take that, which is just away to use a number to make some descriptive statements about some population.
[00:10:35] When we take that number and we decide it's meaningful. It's like a somehow a meaningful number that we would, that would tell us something if you were on either side of it. Of course it's not. And when you're using it for populations, for individuals and populations on which it was not based, I mean, this is a much deeper issue, but when we talk about BMI in particular, this is something, these are sort of cutoffs that were developed with reference to like a white European population, they may have very different meanings and relationships with health for different populations off of which they are not based. So there's a sort of whole other can of worms there.
[00:11:14] LM: Totally. It's, I mean, to make an analogy briefly that you and I are familiar with is, you know, COVID risk, right? It's not that a 65-year-old, every 65 year old is at so much higher risk for outcomes. Then every 64-year-old, but there is truth to the fact that older people tend to get sicker on a population level when I'm talking to a patient who has just turned 65 and who is generally very healthy and active. I'm not going to counsel them in the same way. I'm going to talk to a 64 year old who's technically not at higher risk, who has myriad health problems. So population level data is one thing and then individual risk calibration and counseling.
[00:11:58] EO: Yeah, and I think the piece of this that my senses provoke so much anxiety and discomfort in people is that it is true that, and I don't think you do this, but it is, I think, an experience people either have or fear having in their doctors. They'll be weighed, their BMI will be calculated, and then they'll be told, you know, well, you just, you edged up above, you know, 20, now you're 25.1, and like this is how we're going to define you, and that becomes such an important, like, number in the conversation, and so salient, and the words, I mean, the words we use, overweight versus normal weight, obese, those take on an attention and a meaning, and they didn't just label them BMI category one, BMI category two, which, Maybe would have been more helpful.
[00:12:46] You're really using words that suggest that there's a way to be, which is normal, and then other ways to be. And that, that's, it's just not helpful. It's not, I don't think it's a helpful part of counseling. It starts people off on, on a bad, on a bad foot.
[00:13:00] LM: Yeah, I mean, I think people, for better or worse, look at doctors as authority figures and people who, whose judgment matters. And if you have a doctor who is doing a little tsk, tsk, tsk, ooh, you're getting up there, that has real power in many ways. And so I think that has real power and can do real harm.
[00:13:20] Which is not to say that doctors shouldn't be honest about the data in that patient's situation and what they could do and help to arm them with tools and information to be healthier. It's to say that shame is not appropriate or meaningful in any space, not to mention
[00:13:37] EO: Yeah, and I think the other, the other piece that I sort of spent some time on in, in this, and is actually quite closely related to stuff I work on, is that it's actually, It's very hard for most people to lose weight. Like, we know, I mean, we can sort of put Ozempic, Wegovy aside, but for people just changing diet, changing habits, consistent long term weight loss happens for a very small share of the population.
[00:14:04] And so, when we sort of start with the advice, you should lose weight, which people get, you know, in these situations, often that's just not possible. So it's like giving people a set of advice that they just... They're just going to fail on and then giving it as if, well, if only you could have this kind of willpower, if only you could achieve this, like that would be so important.
[00:14:24] I think the whole dynamic ends up in a place where you're giving people advice they can't follow based on a number that may or may not be that meaningful and isn't very nuanced, and you can easily see why that generates frustration, sadness, discomfort, lack of productive conversation with your doctor.
[00:14:43] And then by the way, turns off your ability to have a productive conversation because now we're like in defensive. Now you're like, well, you know, screw you, don't tell me what to do. What do you know?
[00:14:54] LM: Right? If we learned nothing else during the pandemic, that trust is precious. And when you don't have trust between the doctor or patient, and there's a moralization of human behavior, we're just at a standstill. And so how do you see the data that you've pulled together in this piece and before this piece helping people, individuals who are reading your stuff and then going to the doctor's office, understand better what their weight.
[00:15:21] EO: The piece I pulled out at the end that I thought was really meaningful was, in this piece I'm actually pulling data from the NHANES, the National Health and Nutrition Examination Survey, which is a very big survey of, of people, it weighs them, it measures them, collects a lot of biomarkers, which is why we can say all this stuff about, about health.
[00:15:39] They also collect information about their exercise. And so if you look at people, if you sort of take a, a second, uh, almost a second metric of health and you ask like, okay, does this person do like some, some moderate amount of exercise a week and it's like some cutoff and you look at that relationship.
[00:15:57] One of the things I show in the piece is that doing more exercise is correlated with better metabolic outcomes, better kind of health outcomes in various ways. And it's quit informative on top of BMI, and so people who are doing sort of exercise who have a BMI of like 40 actually have sort of similar metabolic health to people who like aren't doing any exercise and have a BMI that we would consider, you know, normal or, or thin.
[00:16:26] And so I think for me that has sort of two pieces of it. One is that it just again emphasizes like this is one other thing you could like if you said like you can only learn two things about people It's like well, how much more could I add with a second thing? Well, actually like quite a lot the characteristic knowing somebody's BMI and whether they have exercised rigorously or moderately in the last week that tells you a lot more about their health than knowing their BMI alone You could add on top of that smoking… it's just one simple illustration of like how much more you could learn if you ask some more questions The other thing, and here I'm going to reveal what my husband is always saying, it's just like, just because you like to exercise, fine.
[00:17:08] But like, actually, I think we should tell people to exercise. I think that we spend too much time telling people to lose weight with their diet, which is something we know is really difficult, and I think we should spend more time telling people, like, you should go take a walk after, like, try to walk for ten minutes every day.
[00:17:27] You know, actually, it's not saying, like, you need to go run a marathon. But just some aerobic exercise. I think we have a lot of evidence from a lot of different places that that's associated with better health. And I think if we started telling people that and talking about that, we would then get to the questions like, well, how can we make it possible for everyone to do that?
[00:17:45] How can we make there be safe places for people to do that? How can we increase access to sports? How can we be in a position where everybody is welcome to... to go running no matter what, you know, their race or body size or anything? And I think that's, you know, for me, that's something that's pretty, that's pretty important. And I think we're kind of missing with this focus on food.
[00:18:08] LM: I totally agree. And what I love about the NHANES data is what you earlier said, which is that there's an incredibly tight correlation between the amount of exercise and health outcomes, even more than BMI and health outcomes. So when I'm talking to a patient who wants to lose weight or, you know, Needs to lose weight, perhaps I often tell them, let's not think about the number.
[00:18:35] In fact, I commonly say, let's not think about the number. That's not our end point. And, and I'm not saying that to be politically correct, to pussyfoot around hard conversations is because the number on the scale is immaterial. When we were talking about this whole person, we are the complex sum of these integrated parts.
[00:18:57] And you can, as you said have a BMI of 40, which is technically obese. But if you are exercising on a regular basis, first of all, your mood is better, your sleep is going to be more efficient, your blood sugar control is going to be better, your blood pressure is going to be better, most likely. And so, I focus, with my patients, less on the number and more on the behaviors.
[00:19:21] The relationship with food, not just what you're eating. The cadence of how you're eating. Sometimes you don't need a fancy diet, you just need to have lunch. I just wrote a piece about that. Lunch is an underrated food group, like eat lunch. Honestly, that is huge. Sometimes we don't need to, you know, go to the doctor and be told that our weight is technically higher than it should be.
[00:19:43] We need to be given materials and information on the benefits of exercise. Not just on our weight, but on our mental health, our metabolic health, our cognition, and not just... Are you told to exercise, but to help people figure out where to put it and how to incorporate it in their everyday life. Because as you know, telling someone to exercise is one thing, helping them figure out what to do is another.
[00:20:10] So I think you're absolutely right, Emily. We need to treat people, not just as a set of metrics and data, but as people. And as you know, from your research, human behavior is complicated. We do things that don't serve us all day long. Even doctors do, which is again, ridiculous, why I would shame anybody for a behavior that's part of the human nature.
[00:20:30] So to do a lot of shooting with patients or to say you should do this is less productive than to say like, how do you think you could incorporate a little more movement because of the data on the benefits of regular movement into your whole health?
[00:20:44] EO: I actually think, you know, when we do this kind of counseling and when people hear this counseling and they hear, they sort of hear the phrase diet and exercise, like you should improve your diet and exercise. They think of that as improve your diet and exercise so you'll weigh less. And that's the link we should sever.
[00:20:59] It would be, I think there's a place to say, improve your, let's think about are there changes you could make to your diet that would make you feel better? Are there ways for you that you could incorporate exercise, which by the way, like 10 minutes of walking slightly faster than you would otherwise, that's exercise.
[00:21:16] That's an exercise activity, so just like making it clear that these things are possible. But also without saying, and if you did that then the number will look better on the, no, if you did that maybe some of these elements of health, metabolic health, maybe some of this would improve, your sleep might improve, your mood might improve, that's what we're aiming for. We're not aiming for some number.
[00:21:37] LM: That's right. And by the way, when you're sleeping better and your mood is better and your dopamine hormone axis is being triggered by the lights of being outside and feeling more fit and getting the endorphins going that is good for our metabolic, metabolic health too. But I also want to be clear that I don't shy away from talking about a number when it is relevant.
[00:22:00] So if somebody has bilateral knee osteoarthritis, bone on bone, and their BMI is 40, and they're resistant to, you know, getting a knee replacement, we have to talk about weight. So it would be irresponsible for me to say, oh, weight loss isn't going to matter to this gravity-dependent set of joints. And so that is where it gets really hard, but it is where I actually like for me it's my like superpower is never to have judgment about it because by the way when you have bone-on-bone arthritis in your knees As a result of age and genetics and weight all together you can’t exercise and You gain weight more easily.
[00:22:43] And so this is what happens. So there's no shame about it. It's just, let's figure out what to do. But we have to talk about the number, not just the number, but we have to talk about what weight might make sense to that offset pressure on the knee.
[00:22:56] EO: Yeah, I mean, that's such an interesting, like, it's, this conversation is so hard because it takes, like, it's so hard to have that conversation. And I bet you are really good at this, but I think for me, it's very hard to have that conversation without it feeling like shame because of the, as opposed to just saying, look, there are a bunch of things, like, there is a physical reason why this, this number matters, not because this number has to do with whether you're a good person or not a good person or have willpower or whatever, it's just like, this is putting pressure on your knees.
[00:23:23] LM: Well, and that's why I'd really like to reinvent the healthcare system to have doctors incentivized to have more time with their patients to understand their story and to build trust and rapport and for patients to feel comfortable and then to train doctors on sensitivity on these subjects. Which, by the way, doctors went into medicine, the field of medicine to do that, but it's just people don't have time and then people don't trust and then there's diet culture and then it's just lose weight, exercise more, see you next year.
[00:23:50] EO: This is totally off topic. I mean, it's a little bit off topic, but, but one of the things that's been pretty effective in, you know, obstetrics is these group prenatal care. People have exactly this sort of same complaint about, like, there isn't enough time to talk about all the issues that have come up, da, da, da.
[00:24:05] And so they do these things where it's like six people, but you get two hours, you know, and we do, like, there's this sort of examination component that happens, like, that's short for each person, but then we all, they, people all talk together, and it turns out to actually be, some good evidence on the relationship between that and preterm birth, particularly for black women.
[00:24:20] So I wonder if there's like, I almost think there's like a parallel care model, where it's like, we have a group of people here for counseling about, you know, whatever it is, improving their heart disease metrics or something.
[00:24:33] LM: Yeah, stay tuned for some courses I'm going to be offering in 2024. One of my little kind of mantras is that health is about more than BMI. It is about having awareness of our health ecosystem, which includes ur story, it includes our data, it includes understanding our genetics, and then sort of a laddering up to acceptance of the things we can't control.
[00:25:01] Maybe we are predestined to have a higher-than-ideal body mass index because of our genetics. And we have to accept that. We have to accept that we are predisposed to diabetes. And then agency over the things we can control. So, arming yourself with tools and information to carve out space in your life to work on the things you have control over, which are a lot.
[00:25:26] But if you're stuck in the acceptance bucket where you're not accepting hard parts of your genetics or your story that you can't control and you're then listening to a lot of kind of wellness gurus who are telling you that, you know, thin is better or whatever, even just all this messaging. And then you're spending a lot of brain space trying to accept things you really need, or trying to control things you can't control, that's where people run into trouble, and that's where shame is born, and that's where people, frankly, binge on things like food and alcohol, and that's where we land in trouble. And so if we could just help people understand they're not alone, they're human, and that we all have our challenges. One of them, for a lot of Americans, is weight.
[00:26:12] And that they're not alone, and that there are things they can do to be a lot better off. So... What was the takeaway from this piece you wrote? Like, what was the reaction? Because, as you said, like, there's sort of two camps. It's like health at every size, there's a movement, which I agree with in many ways, except that there are certain medical realities we have to acknowledge.
[00:26:32] And then there's the sort of, weight is genetic, and there's nothing you can do about it. And, I mean, there's just, there's just these false dichotomies.
[00:26:39] EO: So I think like with most things, most people are in the center. And so this kind of like, I think that many people found this interesting. You know, I'm not sure everybody thinks about this data quite the same way, and sort of seeing some graphs about it, it made some people think. A bunch of the comments were like, yes, like I started exercising, and I felt like this is very validating, because like, that, you know, that totally changed, but then my weight didn't change, but still I feel better, and I was trying to understand that.
[00:27:08] So there was like some good stuff there. And then I did get, certainly, some people who said, you know, talking about BMI at all is very fatphobic and I am, like, I will say, like, I'm a relatively thin person and so I think, you know, I don't know, I guess that's part of, part of it. And then certainly there were people on the other side who said, you know, this whole thing is like, you know, anybody who's overweight is just, you know, is just lazy and I don't agree with that at all. But some of those people fought with each other and, you know, that's what comments are for.
[00:27:39] LM: That's what's comments are for. And that is why Emily Oster is here. Emily is here to help us get to these story issues, and ask the questions that... People are wrestling with every day, like, can you have a glass of wine when you're pregnant? Can you have bluebean cheese when you're pregnant? Can you jettison some of the shame about parenting and the parenting industrial complex?
[00:28:01] And thank God for you because I think you're doing so much good, Emily, and you're reassuring people based on evidence. You're not reassuring people for the sake of reassuring them for you to look good. You're reassuring them because you have the data to show. How to calibrate risk to, or sort of how to calibrate anxiety to the actual
[00:28:21] EO: Yeah, I mean, I see a lot of what I try to do is sort of help people see what those risks are and make the choices that work for them, which [are] going to reflect our own risk tolerances and preferences and, and what's important to us.
[00:28:33] LM: Yeah. I mean, at the end of the day, as we talked about during COVID quite a lot, it's about framing risk. It's not about telling people how to feel or telling people how to choose. It's about framing risk. And then it's like, you do you, and that's fine. And if you do something that's not healthy for you, that is fine too. As long as you're armed with the data, then that, that, that is, that is great. Emily, thanks for joining me. And by the way, how can people sign up for parent data?
[00:28:56] EO: So, parentdata.org, you can find me there, we have a newsletter that goes out, we have an enormous volume of writing for pregnant people and parents and, and some things for people who are not parents, and we have like a little search AI, so parentdata.org is the best place, or you can find me on Instagram at profemilyaster.
[00:29:20] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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Dr Devika Bhushan is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. She has served on Stanford’s faculty and trained at Harvard Medical School and Johns Hopkins. She's a firm believer that life’s trials and tribulations not only improve our self-awareness, they help us flourish.
While serving as California’s Acting Surgeon General last year, Dr. Bhushan publicly revealed her diagnosis in an effort to reduce stigma and spread hope for people suffering with mental illness:
I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things.
Through her popular newsletter, Ask Dr Devika B, she is growing a community to help break down the stigma associated with mental illness. As she says, "Stigma festers in the dark and scatters in the light.”
On this episode of Beyond the Prescription, Dr. Bhushan shares her advice for mental wellbeing. The two doctors also discuss the complex roots of emotional distress; the shame around mental health diagnoses; and the possibility of post-traumatic growth.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
[00:01:02] Today I'm joined by the amazing Dr. Devika Bhushan. Devika is a pediatrician and public health leader who has lived with bipolar disorder for the last 13 years. Devika served as California's acting Surgeon General in 2022, where she focused on initiatives around equity, resilience, and innovation. She's a firm believer that our trials and tribulations can help us flourish, and she's learned this through her own experience living with mental illness. Today we will talk about what it's like to face a mental health diagnosis and the individually oriented lessons she's learned along the way. Devika, thank you so much for joining me today.
[00:01:42] Dr. Devika Bhushan: It's so great to be here with you, Lucy. Thanks for having me.
[00:01:46] LM: So in your op ed for the LA Times last year, you wrote some pretty powerful words. You said, I believe that our struggles can be the source of our superpowers. They can show us our capacity for vulnerability and strength, and that we can endure and overcome hard things. Can you expand on that a little bit? What do you mean by our struggles being our superpowers?
[00:02:11] DB: So my toddler, his name is Rumi. And so it's very apt. I'm going to borrow a quote from Rumi. The wound is the place where the light enters us, and this also hearkens on this Japanese tradition whereby when a ceramic bowl breaks rather than throwing it away, they will actually patch it back together with gold.
[00:02:37] And so at the end of that break, what you're left with is a stronger bowl, a more unique bowl, and a more beautiful bowl. And I firmly believe that when you have a chance to walk through a really difficult time in your life, whether that's because of mental illness, whether it's physical health, whether it is an early experience of adversity, whatever it might be, I firmly believe that once you have emerged through that, and walked through it and come out the other side, you become much more self aware, number one. You know exactly where you're able to stretch and flex and accommodate and where you're going to break. Right. And so that knowledge when you acquire it is something that will never leave you and will always make you a better whatever you decide to do after that.
[00:03:29] So, for instance, like for me, I know that. I can endure a lot. But one thing that my brain, and anybody with bipolar disorder's brain, might not be able to tolerate is actually a lot of circadian rhythm shifts. So, for instance, when I was in residency training, I didn't really internalize this. The fact that I should, from the get go, be really careful about day night switches, about 28 hour calls.
[00:03:53] And I learned the hard way that those experiences led me to have mood episodes that required me to be out for three months, two months and really struggle to find an equilibrium again. And so that's number one, right? Like you learn exactly what you're capable of and what you cannot do, where your boundaries need to be as a person.
[00:04:13] Number two, I think you learn that there are superpowers that come from enduring really difficult things. So for me, one of those is that I'm a really deep empath and I really understand other people's struggles and vulnerabilities in a way that I don't think I would have if I hadn't had such deep and dark experiences of my own.
[00:04:36] And so when, you know, when I was a practicing pediatrician sitting with patients, sitting with families, walking through very challenging things, I could connect with how they were feeling and sometimes give them lessons from my own experiences when those were relevant in a way that really helped me be a better pediatrician. And I similarly found that when team members of mine, when I was the leader of a team, when folks would go through stuff in their own personal lives that was difficult, and impacted their work because we're all human beings first, and whatever's happening for us at home or outside of the work context does show up for us at work, I was able to connect again with what they were going through and help them make the space for whatever that was in a way that maybe a leader who hadn't had their own struggles wouldn't have been able to do. So I think on both of those levels, people don't always, acknowledge or talk about the ways in which struggles lead to superpowers.
[00:05:39] But that's a firm sort of belief of mine. And when I'm, for instance, interviewing podcast guests of my own on my podcast called spread the light with Dr. David Gabby, also published in my substack. One of the questions I always ask people is, “So how do you feel like this experience led to your unique strengths or superpowers?”
[00:06:00] And people always love reframing their experiences and distilling those strengths down for people. And I'll tell you, when I published my LA Times op ed, which you quoted from, that was the line that people most resonated with. And that was a line where people specifically said to me sometimes, “You know what? I never thought about my chronic PTSD or my... OCD or my borderline personality disorder as giving rise to these superpowers that I have. But you are so right. That's exactly how I experienced this. So I think it's a very empowering frame and it's an important one,
[00:06:35] LM: I think you're right. And I think mental health is having this moment, rightly so in the popular vocabulary, right? We've been talking about the mental health toll of the pandemic. We've been talking about the, the grief, the loss, the trauma people have experienced. And I think it's fantastic that we're finally identifying mental health as part of whole health.
[00:06:59] I think sometimes though people are confused about what mental health means or what it is. And I think sometimes we think that mental health means that you're happy or mental health means that you're content, mental health means you're not anxious And so I'm very clear with my patients and with my own kids and hopefully with myself as well, that mental health is really about that laddering up from self awareness that you described to acceptance of the things We can't control like we cannot control, for example, genetic predisposition towards bipolar disorder or breast cancer or what have you, and then leaning into the agency that we have and so mental health to me is really about self awareness.
[00:07:45] It's about sort of an understanding of where we can flex, where we have that extra Reserve and then where we need to hold a boundary. And so I think it's important to recognize what health, what mental health is. It's about having the resilience, the self awareness to weather the storms that inevitably come our way.
[00:08:06] It's not about being happy all the time. Happiness is great. We're not against happiness. We're all for happiness. I'm believer in contentedness, but I think it's those tools and that we have to get sometimes the hard way that are the most kind of beautiful and that the things we don't often count in our kind of resume of life skills.
[00:08:25] And I also want to say that Rumi is an old soul. Clearly he understands that even at two years old, when we break is when we repair as well… can shed some wisdom on our resilience. So let's talk about kids for a minute. So in your role as the acting Surgeon General in California, you did quite a lot of work on adverse childhood experiences or ACEs.
[00:08:49] And many people who are listening understand that there's an abundant amount of literature about the effect of adverse childhood experiences or ACEs on social, emotional, mental, and physical health issues later in life. So some of those are my patients, people who have had some sort of childhood experience of neglect, abuse, trauma, that shows up in their bodies in the form of hypertension, an anxiety disorder, binge eating. Our stories live in our bodies. And I commonly try to help patients with various physical problems by looking back at what happened, what's behind the curtain that we can then kind of connect to their current physical state. And it's often the case that a patient who's struggling with binge eating disorder and diabetes gets better when we put them on metformin and we get them in trauma therapy to work on kind of pulling the curtain back on what happened.
[00:09:48] And helping them understand that hypervigilance that was organized around a traumatic childhood experience shows up later in life. And that's, I mean, that's the most kind of fun part of my job, if you will. So adverse childhood experiences show up as social, emotional, mental, and physical health problems in patients later in life. And so I'd love to hear about your work on adverse childhood experiences and do you agree with me that they show up in our bodies, that our stories live in our bodies?
[00:10:18] DB: That is such a beautiful way to put that. And I could not agree more. Our experiences, whether positive or negative, end up living in our bodies, and they end up living in our bodies at a cellular level, at a organismal or organ level, um, systems level, and even for all, for the whole body, right, the whole system.
[00:10:39] And what we recognized around ACEs, so all of the folks listening, are probably well acquainted with this term, but these are essentially 10 experiences that are really difficult before you turn 18 years. So child abuse, neglect, growing up in a household where maybe somebody had an untreated mental illness, intimate partner violence between adults in the home, things of this nature.
[00:11:02] And basically what happens is that you're exposed over and over again to a threat and a stressor that is extreme. And so your threat response system and your stress response systems end up being activated and have trouble getting regulated and have trouble turning back off. And what happens is that can change the way that your brain develops, your hormonal cascades, your immune system, even your genes and the parts of your genes that regulate cellular aging.
[00:11:34] So those are called telomeres for those who are aware of this term and familiar with it. And so, you know, when you look at a population level, there is this dose response relationship between the number of ACEs you've had and all sorts of health outcomes, anything from cancer to heart disease to, of course, mental and behavioral health disorders.
[00:11:53] There's about 60 or more health conditions that you're at risk for. But equally, we know that being really intentional about turning off the stress response and using that, just as you mentioned, as part of the treatment plan for a patient who's coming in with a history of trauma and let's say diabetes or heart disease. If you are not intentionally looking at that toxic stress response that's in the background that has been with them potentially for years since their childhood and you're not specifically intervening on that toxic stress response, then you're leaving part of the physiology on the table.
[00:12:32] So the ACEs Aware initiative, which we launched at the end of 2019, just before some of the biggest traumatic events of our lives were to unfold during the pandemic, the plan there was to really help health care workers of all kinds understand toxic stress physiology. And so, you know, there's a lot of talk about ACE screening, whether, you know, universal ACE screening is worth it on an individual level.
[00:12:59] We know all of this stuff is true at the population level, that ACEs will put you at risk for these health conditions, that sometimes the link gets lost. So the point of ACEs Aware Initiative is not, in fact, to say, do you have ACEs or do you not have ACEs? It is actually to say, hey, are you coming in with health conditions and symptoms today that are rooted in a toxic stress response? And if so, if you're at risk for a toxic stress response, how can we specifically cater your healthcare to be more individualized, and to not only give you the metformin for your diabetes, but also to help you understand that trauma therapy, as you mentioned, or anti inflammatory nutrition, or certain exercise habits, sleep habits, connection, etc., that there are these other evidence based behavioral strategies that we have in our toolkits as healthcare providers, as individuals that we can start to use to specifically turn off the toxic stress response as a way of treating somebody.
[00:14:02] And so that, that message of hope is, I think, really important because we often talk about ACEs as posing risk for health, but we don't spend equal time sometimes talking about the fact that we do have these evidence based tools for enacting resilience if you do have toxic stress. In other words, toxic stress is preventable. And once it's in place, it's very treatable. And so that was the overall mission that we were working on at the ACEs Aware Initiative.
[00:14:31] LM: I love it. And then on top of it, there is the opportunity to make meaning and to find out where you can flex and where you need boundaries based on the self awareness from the work you might need to do on your toxic stress. So, let's talk about your childhood. Do you look back, Devika, on your childhood and see threads of your bipolar illness that predated the actual diagnosis? And, you know, to the extent you want to share that, I mean, how do you make sense of things that may have happened to you, good and bad, and the evolution of your mental health story?
[00:15:10] DB: It's a really important question. As we know, most people who have mental health symptoms, it's most common to start to have the first symptoms when you are in your teenage years or in your early 20s. And for me, my very first symptoms happened when I was in medical school. I didn't have any kind of sign of mental health instability or any kind of mental health symptom when I was growing up. I did have a very unusual childhood in some ways. So I spent… my first 21 years about a third in three different countries. So the first one was India, which is where my family is from originally and where my majority of my family actually still lives.
[00:15:52] So we started there. I was seven when I left India, and then we came to the US for a few years where my parents were grad students here. Very stressful set of circumstances financially and otherwise. And then we went to the Philippines for my parents’ jobs, which were in health and development. And we didn't know anyone in the Philippines when we first arrived, and we were supposed to have spent three years just trying it on for size.
[00:16:18] And my parents ended up spending over 20 years there. So it was a big part of our lives and big part of their careers. And so, within each one of those countries, even there was a lot of moves. So by the time I was in fifth grade, I was 11, but I had been to seven schools in three countries. So there was a lot of changes and a lot of transitions and a lot of figuring out who I was culturally, you know, where I belonged.
[00:16:45] There were these kind of deep existential questions taking place, although I will say my four person family, so it's my sister and I and two parents are a very close knit unit, and so that unit kept us grounded and it made us feel like we were in home, wherever we were and you know, that, that made all the difference because I think I felt very grounded growing up despite the fact that things were changing on us so often.
[00:17:14] And I felt like a lot of folks who have multiple cultural influences, multiple languages. I grew up speaking Hindi, then had to learn English and. You know, uh, the whole, uh, getting made fun of for my accent in the U S and trying to get rid of that accent overnight, you know, all of those different pieces of like, am I Indian? Am I American? Do I have influences from the Philippines, but I'm not quite Filipino, even though I've spent so many years here, there's all of that stuff growing up, but I will say kind of back to your question, nothing that really would qualify as a mental health symptom, just sort of common experiences around moves and cultural identity that I think anyone would have with a similar set of circumstances.
[00:17:59] And it wasn't until I hit medical school, as I was saying, I was 23 and my first symptoms were of the depressive variety. And I didn't have a family history of bipolar disorder. I didn't have a personal history of either hypomania or mania. And so it looked for all the world, like garden variety, unipolar depression, right?
[00:18:19] And I was treated with antidepressants, which ended up over the course of three years, not working and making my brain worse, which is typical when a brain is on the bipolar spectrum. So often what'll happen is you'll induce sort of the little bit of activation that's not recognized. It's actually hypomania in retrospect, but might just look like anxiety on top of the depression, right?
[00:18:42] And that's essentially what happened to me. I had about three years where I was on the wrong meds. And I tried 20 different meds, you know, in that span of time. And luckily, you know, three years in, I was on three different activating meds and had a frank manic episode. And that really saved my life because it allowed people to understand that I was somebody who had a bipolar spectrum disorder rather than a unipolar depression with anxiety on top of it, which was the working hypothesis.
[00:19:12] And that led me to have the right condition diagnosed and also the right treatments then in place, which, which really, really truly saved my life.
[00:19:21] LM: I want to interrupt you to say, well, I don't want to interrupt you, but I would, I want to say thank you for sharing that because I think there are a lot of people, I don't know the number. I don't think we know the number of people who are suffering with bipolar disorder, who are called. Depression and anxiety, right?
[00:19:39] I mean, depression and anxiety are extremely common conditions. You know, certainly if people have enough depression, they can be anxious about it. If people have enough anxiety, they can get depressed. But I do think there is a subset of people who are inappropriately treated who actually are on that spectrum and they didn't have that manic moment or the doctor to understand that's what that was.
[00:20:02] And then they get further medicated and then sort of down a pathway that isn't appropriate for their diagnosis. So, I mean, did you have trouble recognizing sort of activation, the activation driven by the antidepressant that was then maybe the beginnings of your, of mania? Or did your doctor, like, did it go for a long time without being recognized? Or how did you make sense of those initial failures of the antidepressants?
[00:20:30] DB: It was much more clear in retrospect, you know, we had these three years where I did not feel like myself and I wasn't, you know, depressed for all of that time. At some points I was, you know, hypomanic where I might have been euphoric, right? And just tripping too quickly in terms of the energy and the thought processes.
[00:20:49] Or I had periods where I was hypomanic, but in a sort of dysthymic state of mind, meaning I was just activated and energetic, but I was irritable and angry and anxious. And it wasn't really recognized. Now in retrospect, it's very clear that, okay, all of that was hypomania. But at the time, when you're dealing with, you know, a 23 or 24 or 25 year old, because I crossed all of those numbers as we were seeking treatment, it just felt like, okay, this person is not responding to treatment.
[00:21:24] And as a patient, you feel very vilified because the statistics will tell us that most people with bipolar 2 disorder end up having symptoms that are mistreated for an average 11 years from the first time they're symptomatic to the time that they get the right treatment in place. And I was lucky that mine was only three years, but I will tell you, they were the hardest three years of my life, like, I was considering dropping out of med school, I didn't think I could hack it, I thought it was something about medicine, potentially, that was kind of triggering these symptoms that I'd never faced before, I was also pretty convinced that, like, the person that I thought I was pre symptoms, was completely gone, inaccessible, lost.
[00:22:11] Like, I would never find that person again. That I was just somehow stuck in this place of unwellness. And I think that's something that most people who have ever had any mental health symptoms can really relate to. Like, in the midst of it, you feel like you are never gonna be well again. And whoever you once were is no longer a person that you can access. I think that is the hardest part when I look back at that period of my life of true terror that I was never going to be myself again.
[00:22:39] LM: There's so many things I want to react to that with. First and foremost is deep gratitude for saying that because I think as I talk to patients with mental health issues, as I talk to family members with mental health issues, as I've talked to my myself when I've been struggling with mental health myself, there is this hijacking of our own brains that happens where you [become convinced that you're never going to feel good again.
[00:23:03] You're never going to feel okay. You're never going to be that person that you thought you were. And it's terrifying. And I think to see someone like you, Devika, who is, I mean, beautiful, healthy, accomplished mother and physician, it just gives people hope that this is not a death sentence. That it truly is a hijacking of your brain that is not a permanent condition and that you can get better.
[00:23:32] I think it's important for people to realize that if they are getting treated for depression or anxiety and they're not getting better, not getting better. You need to ask the question, is there something else going on? I mean, 11 years is too long for people to get a diagnosis. Bipolar 2 is not a zebra.
[00:23:47] I don't know the stats on the commonality of it. I don't know because I don't think we probably have accurate statistics at all. I mean, because it takes 11 years to get the diagnosis, but I know from my own experience seeing patients, I will commonly make a referral to a psychiatrist when I, for example, have tried my patient on Lexapro for what seems like unipolar depression and they're not better, or they have a little bit of an uptick in their energy, irritability, and then we ask the question.
[00:24:12] Because for people who are listening, a diagnosis of bipolar one or two, which are a bit different, we can talk about that, opens the door to another set of medications for treatment. This is one of the things I worry about with online, kind of drive through kind of mental health startups. I mean, I think it's great that people are getting better access, but I worry that we are bucketing people into depression, anxiety, depression, anxiety, when sure there's a lot of depression. There's a lot of anxiety, but first of all, do we need to medicalize all of it? I'm not sure. And secondly, are we making the right diagnosis in the first place?
[00:24:46] Such important points. You know, I think just stepping back, like, from the data, you're absolutely right. There's a whole variety of studies that have been done with differing prevalence rates of bipolar 1 and bipolar 2, depending on sort of what is counted. And it's very common within the bipolar spectrum for you to receive let's say one kind of diagnosis. I was initially diagnosed as bipolar not otherwise specified, which is sort of a soft call it's like somewhere in the on the spectrum. We don't exactly know where and then as people's lives go on you end up realizing like okay You've now had a manic episode off of antidepressants let's say, and now you qualify for bipolar one rather than bipolar two, so there's a lot of shifting along the spectrum and that makes it hard to assess and get true prevalence rates. there's a meta analysis that came out now about 10 years ago, and they said that 2.
[00:25:32] There's a meta analysis that came out now about 10 years ago, and they said that 2.6 percent of the population will meet criteria for bipolar one or two at any given time. But that's not counting the other parts of the spectrum, which we now know is also a sizable portion. But, you know, with depression, when people come in for a first time depressive episode, one in three of them. will end up being on the bipolar spectrum.
[00:25:59] And so if primary care doctors know this, if, you know, other kinds of healthcare providers know this, then we can start to turn the tide on that statistic of 11 years for bipolar 2, and it's shorter for bipolar 1 because it's much more obvious when someone has a manic episode, whereas hypomania can be a little bit more, it can cloak itself as anxiety as you said, and other symptoms that are harder to diagnose.
[00:26:23] LM: So what prompted you to be public about this? I mean, it's a pretty big move. I mean, there's a lot of stigma around mental illness, even though it is having a moment. There's a lot of misunderstanding about what bipolar is. I mean, I think people throw that word around a lot. Like, Oh, she's so moody and crazy.
[00:26:40] She's so bipolar as a derogatory term. You know, we used to call it manic depression. I think patients associate bipolar disorder with someone who's driving a stolen Ferrari a hundred miles an hour down the highway. And then someone who's standing on a ledge about to jump. And there's so much more nuance there.
[00:26:58] There's people in our lives. These are people who are functioning, who are parents, community members, people we know. I think it's, it's very brave of you to come forward as you and I were talking about before we started recording, particularly in a public role, like you had as the acting surgeon general in California, I mean, you're out there. So I'm just going to ask you, what is it that prompted you to go public? And what has that been like?
[00:27:25] DB: I was serving in the role of acting surgeon general in a moment in time when everybody was struggling with something, right? We had been in the pandemic for two years plus at that point. And we all, at that moment, knew somebody who was truly struggling, or we were that person ourselves. And so I felt like it was a really important moment to publicly own my story on a couple of different levels.
[00:27:53] One, to help everyone realize, like, you can walk through a really difficult period of your life and think that you can never bounce back from that, but actually walk through it and then, on the other end, be able to fulfill your own dreams, right, personally, professionally. At a point in my life, I thought I'm never going to have a career.
[00:28:16] I'm never going to be a parent. I'm never going to be a stable partner. But to recognize that even a really stigmatized mental health diagnosis like bipolar disorder, and it does carry a very loaded set of stereotypes with it, that even that, you know, you can look back at your hardest moments and say, those were in my past.
[00:28:36] And... The last 10 years or more, I've been well for the majority of them and now, you know, having figured out what it is that keeps me well, both behaviorally and medication wise, I can hope to be well for the rest of my life and I think that it's an important message because unfortunately, for instance, all of the people I know who are living well with bipolar disorder, there's a very small fraction of them who feel comfortable sharing that truth with their coworkers, with their with the people in their lives beyond just a few.
[00:29:11] And so, if we all live in secret, once we've figured out how to live well with this disorder, then we have a very skewed sample of who it is that has bipolar disorder and what that can look like. So number one, I wanted people to know that when you've got the right treatments and the other systems in place to stay well, you can do the things that you want to do in your life.
[00:29:28] And then number two, I wanted to reach those people who were truly still in their hardest phases who are struggling to know that there is hope for a better tomorrow. That with the right treatments once more things can turn around very dramatically. And to have hope that can happen. And the way that it all came about, and I'll just say one quick other thing, which was NAMI California was having their annual conference and they invited me to keynote it and it felt like that would be the most authentic moment in which to share this journey. And I… same day also shared it in the LA times and online on social media. And I'm really glad that I did because in the wake of that, hundreds of people reached out to me with their stories of, I have been struggling and this meant so much to me where my son is in the hospital and I have hope now that he might be coming out and he'll be back to himself.
[00:30:29] You know, it just, it really opened. the door to understanding that we all have this commonality. We all have known struggle or known someone who has struggled very intimately. And then also it helped me understand that I had a way of connecting to this community and join in on a few different advocacy projects, which have been really meaningful.
[00:30:53] LM: I think that's incredible, and I think you're living proof that there is a better tomorrow, and that with treatment, that’s not just medicine, it's behavioral, it's environmental, you can have hope.
[00:31:06] DB: Yes.
[00:31:07] LM: What do you think, Devika, is the most important element of your wellness? It sounds like you take medication, it sounds like you prioritize sleep, it sounds like you try to eat healthy and have boundaries. I mean, if you had like a pie chart for you, and this is going to be different for different people, but what occupies the biggest slice of pie? Is it the medicine? Is it the sleep? Is it self awareness? I mean, could you break it down a little bit?
[00:31:35] DB: Yeah. There's a lot of elements of that pie. I think a big chunk of it, more than 25 percent is going to be connection and community, right? So the people that I rely on a daily basis to, to understand me, to support me, to have fun with me, to, you know, laugh with me. Those people keep me well in, in so many small and big ways, right?
[00:31:58] And then the other pieces are the daily habits, the making sure I'm getting enough sleep. At night, I wear blue light blockers. These are orange glasses that supposedly filter out the majority of blue wavelength light, nightlight, or nighttime. And so sleep is a big part of my life. I really try to do a lot to protect it. I'll tell you one other thing. My husband tends to wake up if my son is awake in the middle of the night or early in the morning. And so that's one strategy that we've sort of got in place to help protect my sleep, which is really meaningful.
[00:32:38] Food, you know, eating a variety of foods. I tend to have sort of a Mediterranean diet over the course of, you know, the day and really, find that important. Exercise… protecting my energy. So, you know, big events, for instance, where I'm spending a lot of time talking about myself, my journey in a conversation like this, it, it tends to be really meaningful and important and also deplete my energy.
[00:33:07] And so I have to be really mindful of how I structure my weeks. So if I know I'm having a conversation like this, I'm going to try not to schedule too many other things in the next week or so. Right. And that gives me some time to sort of rest, decompressed, refill that cup, that energy cup and, and sort of be present and able to do what I need to do in the rest of my life.
[00:33:31] And so just being really aware of what's happening for me mood wise, energy wise. Am I feeling that tension in my shoulders? Like, what can I do differently? Like if I have any red flag symptoms, like let's say I'm starting to feel a little bit on edge or irritable with folks.
[00:33:46] One of my tells is I tend to respond too quickly and with too many messages on WhatsApp. And remember, my family lives sort of abroad, and so that's a big mechanism of contact. But if I'm doing that, that is often a tell that I'm starting to feel a little bit elevated. And just knowing what it is that I need to come bring to bear in those moments to try to reverse where I'm going mood wise and come back into sort of my baseline mode.
[00:34:14] So it's a lot of kind of those maintenance mode things that we spoke about, but also recognizing red flag symptoms and then having a toolkit in place to intervene, whether that's up or down. And that looks different for different people.
[00:34:28] LM: I mean, that is such good self awareness. I particularly like what you said about the energy allocation. You have this busy life, you're a pediatrician, you're a public health leader, you're writing, you're speaking. You're parenting, you're learning from your own two year old. I think women are, I mean, we are just, I think beyond capable and we're interested in so many different things, but I think, you know, that resonates a lot with me too, is this sort of notion of an energy budget.
[00:35:00] Yes, we can do it all, but like, like with everything, there are trade offs, right? So I think that it's important that you're aware enough about yourself and your tank, where you are, of energy to sort of allocate it appropriately. And I wonder if you find like certain relationships you've had to sort of change or if you, or if there are boundaries that you've had to set.
[00:35:22] I know that as I have gotten older, I just turned 50. That I'm a real empath. I love being around people. I also know when my energy is being drained either by a certain situation or a certain set of people. And it's not their fault. It's just, that's just the way my mind and body work together. And so I'm sort of more aware of who, what, where I can tend to over-expend energy and then when I need to pull back. I wonder if boundaries and relationships are something you think about yourself.
[00:35:51] DB: A lot actually. And you know, it's one of those things that we as women are socialized to be very other oriented, to worry about other people's feelings, sometimes at the cost of our own health and wellbeing. And it's a lesson that I think I learned in my late thirties—I’m 37 now—to really honor my needs, my emotional needs, and sort of to know that with certain relationships. That there do have to be some boundaries in place and at the beginning when I first learned about this concept, you know in therapy, I thought, that's kind of I don't know how that's gonna work in an Indian family. Like we're so close. It's a very communal situation even when we're many miles apart.
[00:36:38] There's this like very open expectation that you will be there and vice versa in lots of ways and the concept of a boundary felt culturally potentially inappropriate and what I realized was that I'm putting this boundary in place not to shut this person out of my life, right? Not to have this relationship wither and die, but actually to have a better relationship, where I'm not resentful of them… of something that they are asking of me that I'm not able to do. I realize like it's been such a powerful, game changing thing because I have closer relationships with those same people now because I'm aware of my own emotional needs and triggers and sort of what those boundaries really need to be.
[00:37:24] Sometimes it's something simple like When I see them, I'm going to see them for this amount of time, and there won't be a chance for, you know, necessarily that build up. But it's been, yeah, it's been huge for me, as I imagine for you too, and for many of us who are listening.
[00:37:39] LM: I mean, I think a lot of what you're talking about pertains to the human condition in general. I mean, I think certainly when you have bipolar illness and certainly when you figure out your kit of coping tools, that's essential. I also think for most of us, we need to be careful about our sleep, our exercise, our relationships saying no, kind of recognizing our internal sort of thoughts and feelings and who drains us and who energizes us and meeting our needs, especially as a physician, as a mother, I'm socialized and trained to be empathetic and I am, I think, intrinsically empathetic, maybe not all the time, but I think I am.
[00:38:20] It is hard. It feels culturally inappropriate in my own family and as a physician, as a woman, to say no and to say, I'm so sorry, I can't do that. But I've also learned, like you, that I'm a better mother, sister, daughter, person when I am meeting my own needs, which is not selfish. It's the way I need to be healthy.
[00:38:42] And, you know, sometimes you get it wrong, right? Sometimes you get it, like, sometimes you get it wrong. Sometimes you say no because that's what it felt right. And then you realize, oh, wow, that was actually... at my own expense, but I think that's something that we as women need to practice and I think it is part of a mental health coping kit is to recognize that our needs matter and then to try to practice establishing boundaries and saying no, and you know, we all know that feeling of when you're talking to somebody, whether it's a loved one or a patient or, and they're asking you to do something that doesn't feel quite right.
[00:39:14] And you're thinking no, but then you end up saying yes, and then you're resentful and you can get angry and it's not their fault. We need to own that power and own that ability to say no.
[00:39:24] DB: Absolutely. You know, I'm reading a friend's book right now… Real Self-Care by Pooja Lakshmin. Yes. So I just finished the part about boundaries and two really insightful things that she has in there. One, don't over explain a boundary when you're giving it to somebody because then it seems like you're asking for permission, right?
[00:39:45] And then number two, to your point, allow there to be a pause between the ask of you, and your response. And in that pause, you will figure out does this feel like the right thing to do? Does this feel like a yes but, or you know, a yes and situation? Or do I have more questions? Do I need to negotiate a different situation, right? Or do I need to say no? And you won't know that if you very quickly respond “yes” which is our gut instinct as women again, and taking that pause is where the boundary can actually emerge meaningfully.
[00:40:19] LM: I think that's right. So what I'm hearing from you, Devika, is that your wellness is external. It's about sort of environmental, everything from your nightshades to your medications, to your therapy, to an internal kind of, checking in with yourself on your energy, on your relationships. It's about connection.
[00:40:42] It's about feeling loved. It's about, it sounds like it's about feeling safe. And I mean, I think those are essential parts of health for all of us and it doesn't have to be fancy or expensive. We don't have to buy fancy leggings and show up with a personal trainer and have exotic supplements and be on a yoga retreat in Bali.
[00:41:04] Although, you know, invite me with you if you're going to go, I think it really is about an internal sense of what we need, what we deserve and what, and how we relate to other people that is at the root of our mental health. So I want to just close by reading one more quote which I love from your LA times.
[00:41:23] You said “by sharing my story, I hope to dispel stigma and internalize shame and to help anyone struggling, know that they are not alone. If you feel comfortable, consider shining a light on your story. Stigma festers in the dark and scatters in the light.” So, for anyone who's listening, who feels like writing, or talking to their friend, or their dog, or just their journal, about their story, I think it's important that we acknowledge that we all have vulnerabilities, we all have grief, we all have loss, we all have fears.
[00:41:56] Some of us have mental illness, some of us have... You know, real relationship struggles. And I think that when we talk about them, we can then start to figure out the path forward. And so I just want to say, thank you so much, Devika, for sharing your story, for being such a role model and for teaching us the ways in which you stay well.
[00:42:13] DB: Thank you so much, Lucy, for having me here and for the wonderful work that you do in your sub stack for the whole community. Really appreciate you.
[00:42:28] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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It’s hard enough for adults to navigate anxiety, lack of privacy, and social relationships in the digital era. How can we expect young people to do it?
On this episode of Beyond the Prescription, media expert Dr. Devorah Heitner presents practical strategies for parenting in an era of perpetual connectivity.
She offers a refreshing perspective in her bestselling new book, Growing Up In Public: Coming of Age in a Digital World. Instead of panicking about social media’s role in young people’s lives, she argues that parents should accept that it’s here to stay and focus on the benefits of technology. Instead of blaming social media’s role for the uptick in adolescent anxiety, she argues to uncover and address the root causes of young people’s distress.
She offers practical advice to help kids set boundaries, maintain digital hygiene, and learn how to make mistakes—even while everyone is watching.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter. At lucymcbride.substack.com, and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm speaking with Dr. Devorah Heitner, who is a bestselling author, speaker, and expert on raising kids in the digital world. In her various capacities, Dr. Heitner offers practical advice that's backed by science and research. She's providing tools that people can use to start conversations with their loved ones about how to use technology in our lives in a healthy way.
[00:01:25] Her most recent book, out in September, 2023 is titled Growing Up In Public: Coming of Age in a Digital World. It's an essential read for parents. In short, Dr. Heitner thinks we're worrying about the wrong things. We see the panic inducing headlines, yet social media can be an excellent way to help learn about our kids and help them learn about the world we live in today.
[00:01:48] Devorah, thank you so much for joining me today.
[00:01:51] Dr. Devorah Heitner: Thank you.
[00:01:53] LM: So, I talk about inputs with my patients every day. I talk about things that we put into our bodies and brains, like alcohol, caffeine, food, of course. And then I talk about screens, because screens are something we ingest. They're ubiquitous. And it's not just about how much screen time we consume, it's about our relationship, sort of like relationship with food or alcohol.
[00:02:17] What I love about your work is not only are you exploring people's relationships with screens, you're taking a somewhat counterintuitive stance that there's a lot of research out there to suggest that screens are destroying a generation of of youth. That it is the cause for the emotional and mental health despair.
[00:02:38] So, there's a lot of data to suggest that screens are the biggest evil for our kids, that they are the reason that kids are experiencing emotional and mental health problems, but you take a different viewpoint. You take the view that screens are indeed ubiquitous, but they also can be used as a tool. They can be used as a tool to help us shepherd kids through this complicated part of their lives. So talk to me about how you see screens as a boon, as a way to help parents understand their kids. And not just as something we need to be terrified of.
[00:03:20] DH: Yeah, I think we've been really pushed this idea that screens are the big bad that are really tanking kids’ mental health has been really pushed on us and we ignore a lot of other factors and also like, what are the screens bringing our kids? So as you said, it's not just about the quantity, the minutes.
[00:03:36] The minutes are important, too. We want to live in balance with screens and be able to do other things. But we also want to think about the quality of the experience. If your kid is a creator and is making things online, for example, or collaborating with other kids, or has started a business, or is composing music, or is writing a really interesting blog, or fan fiction, and getting a lot of creative juice and community out of that, it could be a really positive thing in your kid’s life.
[00:04:04] So we first want to look at: what is the quality of experience? What is your kid engaging with? Are they finding community there? Are they connecting with people in a positive way? Is it leading them to other interests? And sometimes, especially in the last few years, when so much of our novelty has come from YouTube or Netflix, and we maybe have forgotten about other kinds of novelty. As parents, we may want to look at our kids screen based interests as a clue. Like, oh, they're watching this kind of content on TikTok. What else might be interesting? My kids are very into strategy games on the computer, but we've also gotten into risk and some other deep strategy board games.
[00:04:41] And part of that was like recognizing these multi layer, multi hour games, you know, with strategy and complexity are really interesting. What can we do as a family that might also be related to that? And then we also want to think about the ways kids are connecting with other humans and how this is supporting their friendships. So there's a lot that's going on socially here and we worry about the negative pieces, but we should also look at the positive ways our kids are finding affinity with other kids. Our kids are finding community and finding people who share the same interests.
[00:05:12] LM: I hear you loud and clear. I think headlines that scream: watch out parents. Your kids have a separate life that you don't know about and it's only nefarious and screens are doing harm and only harm are sensationalist and really put sort of fear in the driver's seat of our roles as parents.
[00:05:32] I do think there's a lot to be worried about. I mean, kids are looking at images that you and I never had access to as children. And I think that kids can certainly get lost in a screen addiction. Just like you can be addicted to marijuana or alcohol, you can get addicted to screens. You can develop a relationship with screens such that you're using it to “medicate social anxiety” or fear of failure or you can be bullied online.
[00:06:02] Of course, I think we all know about the harms. The way I practice medicine as a physician is that I try to be a realist. I recognize that alcohol is ubiquitous in our society. I'm not going to be able to take it away from everybody, nor should I. We have to reckon with these phenomena. We can't just mop up risk and make it zero.
[00:06:21] We have to reckon with the realities of our everyday life and screens are not going anywhere. Screens are, if anything, becoming more and more woven into the fabric of our society. So I think what's important as you're saying is to recognize that there are opportunities here. There are ways that we can use screens as a sort of window into our kids lives.
[00:06:46] And that policing them may do harm in and of itself. I mean, what do you make of this idea of restricting kids access to screens until they're 18? I think there's a new law in Utah, for example.
[00:07:00] DH: I think the Utah law is a particularly harmful example. Like I do think when school districts and other folks are trying to push back on the big companies and say, “hey, when we report bullying, we should get a response right away.” Or when we report that our kid started an account under age 13 when they're supposed to be 13 and you don't take it down or you're not doing anything to even pretend to try to age verify and any eight year old can start an Instagram account if they can do the math to change their birth date, then I think it's important to say, yeah, we do want to push back on these companies. So I'm excited to see some states and school districts pushing back on the big companies. Utah's saying, let's put this all on parents. Like parents don't have enough going on and parents should be in charge of their kids social media up to 18.
[00:07:44] I think that's a problem for a lot of reasons. One reason is that not every kid is lucky to have enlightened, wonderful parents. So, what if I'm a gay kid in Utah and my parents don't know and if they find out, I'm going to become unhoused? It's not safe for me to post on social media if my parents have access to my social media up to 18.
[00:08:04] I think 18 is particularly glaring in a state where kids can work at 16 and drive at 16. I think to say that driving and working a job are, are less responsible than posting on social media is a problem. I think when we look nationally at what's going on, where there are states saying we want kids to be able to work dangerous agriculture jobs with pesticides and work in meatpacking plants at 14, but they shouldn't be able to post on TikTok till they're 18.
[00:08:30] I think we're a little messed up as a society if we're saying that, because if we actually wanna protect kids, yes, I think none of us want our children to see pornography, for example. We don't want our children to see extreme violence, but the companies need to take down some of that content when it's getting reported.
[00:08:47] But putting that on parents and saying parents need to be checking their kids' messages and reading their kids' posts up to 18. I went to college when I was 16. I moved away from my house and went to college. I'm not saying that was necessarily the best thing in the world, but that's what I did.
[00:09:04] And to sort of say that, and many kids start college at 17 because that's when they finish high school. So to say that a college freshman in Utah, their mom should still be reading their direct messages is just a little extreme. And I think we really need to get out of that idea of big brother and think about we need to teach kids to swim, putting the electric fence around the pool is not helpful and kids entire focus will just be saying that they don't live in that state or that they're going to change their age in some way when they sign up and many parents will not be in a position to make that not happen. And again, it also assumes that every kid has a well meaning thoughtful parent on their side.
[00:09:39] So there are tremendous problems with that. What if a kid needs to use social media to report abuse in their home?
[00:09:44] LM: So do you think that the headlines about the harms of social media on kids and adolescents mental health are overblown? Or what's sort of your take, in general, on that sort of frenzy,
[00:09:54] DH I think they are overblown because it's an easy thing to blame, but some of the problems that we're seeing in kids, we have to look at the pandemic. We have to look at school shootings. We also, when we see more kids reporting mental health issues, we have to look at access to mental health care as a plus.
[00:10:09] When I was growing up in the early 90s, and there was a smoking lounge in my high school, and many peers were using substances to self medicate. Very few kids would have self identified as depressed or anxious because they didn't necessarily have that language. I would argue that there are kids who are learning the language of mental health from places like TikTok or Discord and are using that language to describe the way they feel, but I don't know that those problems are new to this generation of adolescents. But I think we're seeing increased access to both language around mental health, and hopefully in many communities, actual mental health care. The thing I would worry about is I don't want kids to get their mental health support from TikTok and Discord. It's one thing to identify, like, maybe I have an issue, and learn about it, or have a YouTuber who talks about ADHD and say “oh, I think maybe I should get neuropsych testing.”
[00:10:56] What we don't want to do is self diagnose from YouTube or TikTok, and I'm sure you see that as a physician all the time. Like, that, Is concerning, but the fact that more kids are self identifying with mental health issues, I think is partly that we as a society have shifted to destigmatize that conversation and I actually think social media is part of that in a positive way for kids. But it sounds scary to adults to hear like this many kids say that they're depressed or anxious, but it's not that kids in the past were not depressed and anxious. I think they were self medicating in the smoking lounge at their high school.
[00:11:28] I think adults were turning a blind eye to drug use and other things and alcohol use. So I think we're in a really different place as a society where we're looking harder at adolescents. And there are many reasons adolescents are feeling anxiety. For example, if your kid is looking at their social feed or at the news and information about school shootings, that's distressing, but taking away Instagram doesn't take that distress away. They're going to get that news another way. Their phone may be, in fact, the source of where they're getting that stressful information, but that doesn't mean that if we just take away the phone, they're not going to be worried about it anymore.
[00:12:07] So I think it's really important that we look at, is this a vehicle for getting access to stressful information? When we see the apps themselves encouraging things that are stressful, like the apps themselves may be a problem when they encourage us to location share and we can see that our friends are out without us. And that is a problem that I blame more on social media, versus, you know, that's not just getting information. That's kind of random. That's like, hey, this app is really encouraged us to do this very human thing, which is to want to know where the people we care about are, which is very human. But it's kind of trading on that brain what we want to do.
[00:12:41] And it also trades on parental anxiety when parents put Life360 on their kids devices to track their kids all over town. But that may also not be great for our relationships. There may be ways where that undermines trust and undermines relationships. So I think there are times where what we in the tech world call affordances, but it's basically like what the apps let us do become a problem. And that's where I think we should be looking at do we want to change our own behavior or do we want to make some feel really empowered in relation to an app? Like, yeah, I want to use Snapchat, but I'm going to turn off Snap Maps. I don't want that feature. Or I'm going to turn off location sharing on another device, or I'm not going to use Life360 unless someone actually has disappeared and I haven't heard from them way past curfew.
[00:13:20] I'm not just going to use it to see if my kid might have relationships or errands to do that. I don't know about right now to kind of resist, in other words, the possibility of what apps let us do and make choices about how we're going to use tech that might be healthier for us mentally. So to come back to the headlines, I really don't think we should panic about the ways kids are using social, we need to also just look at our own kids. Like if you have a kid who's predominantly using discord to connect with their three best friends to play a game every day after school, then my worry is, are they getting their homework done? Are they getting enough sleep? But I'm not worried that social media is making them depressed because it's clearly functional for them.
[00:14:02] LM: Right? I think as parents, the screen landscape can make us feel very out of control. Kids in their adolescence are naturally kind of differentiating themselves from their parents and they are behind closed doors a lot of the day and we don't always know what they're looking at. But that's always been the case. And that's part of growing up. That's part of developing our identity is being around our peers. And sometimes that's online. So what do you say to a parent who has, for example, an adolescent who's kind of less accessible verbally, who's spending a lot of time on screens, who you may be worried that they're spending too much time on screens.
[00:14:44] How do you even begin to sort of query whether or not you're doing a good enough job as a parent vis a vis this child and their screens? They don't want to talk about it and they don't want to share with you what they're doing online and you feel completely anxious. And then you look at the headlines and you think, Oh my God, I'm the worst person alive. What do you say to that parent?
[00:15:02] DH Well, it depends on the kid and what your specific worries are, but I do think you could have especially a younger kid who's newer on some apps, like walk you through some of the things they're doing. Like, “hey, can you show me some of the things you love?” You know, like my 14 year old will absolutely show me, you know, things that he thinks are funny from YouTube sometimes and like just getting a sense of like, oh, I can see you're diving into some political satire here.
[00:15:24] I see you're diving into some remixes of the culture and things that you're interested in and movies that you like over here and just getting a sense of like, what is the content? You can decide if the bedroom is a place for screens. Certainly with sleep, I would strongly recommend not having connected devices in bedrooms overnight, especially for younger adolescents who will really struggle to self regulate, or tweens, or younger kids.
[00:15:47] And the challenge is sometimes kids are getting phones so young that they're still little and compliant. You know, your 5th grader, if they get a phone, might be super compliant and put it away at night. But you gotta think ahead to that 8th or 9th grader in love and think about, do I want them texting their sweetie all night?
[00:15:59] Do I want them, you know, on social media late at night? And so it may be that the bedroom is a place where tech doesn't go or it doesn't go during sleep and overnight. And I think that's important to think about. So some of their tech use hopefully is around the house for younger kids. If they're gaming with friends, I would suggest not having headphones on all the time.
[00:16:17] It may be annoying. It was definitely annoying for me living in a small apartment through a lot of remote school in the pandemic. And my kid was gaming without headphones. It was extremely annoying, but I knew what the friends were talking about. And when some things came up on Roblox, where they ran into some content that was a little bit of a surprise, as in, like, naked blocky people having sex in Roblox.
[00:16:38] When I heard them start to talk about that, I was like, walking over to the computer, like, what's that? And so I think that's, that's a helpful way. It's a little bit less big brother-y than using your device to kind of spy on or get your kids data later, but just being in a place where you're adjacent, you can overhear some of the activity can help you know.
[00:16:57] As kids get older, their privacy is going to be more and more appropriate, but you can still check in with them when they're in the car. We have a no phones in car rides rule for under a certain amount of time. So, you know, my kid can't like put on a podcast and listen to it with his headphones for a five minute ride if I'm driving him somewhere.
[00:17:14] If we're going on a road trip to another city, podcast and listen together. And some of his time might be in the backseat. with music on or something. But shorter rides, we have to talk to each other. And some of that is like, he gets to pick the topic because he doesn't like to share about school, but he has to tell me about something, right?
[00:17:32] And it might be the video game he's playing, but we have to talk to each other. And family meals are important. Finding a time that actually works. And with busy teenagers who do a lot of activities, that might be late at night. And that's when your kid's ready to spill and you might be ready to fall over, but if your kid is ready to tell you about things, that's a good time to be listening.
[00:17:52] If there's a specific where you have, like, say you think your kid is. checking out pornography or something where you're like, this is a specific worry. I do not want you doing that. Then I would address it directly. A lot of us are uncomfortable there, but if you have evidence that your kid has looked at pornography, I would definitely talk to them directly about it and talk to them about why this isn't where you want them to learn about sex and consent and relationships.
[00:18:14] And we can do that in a non-shaming way. We can normalize and humanize that human beings have been preoccupied with the body and sexuality and art for a long time. This is not new. For an adolescent to be curious about sex and what that looks like and what people do is very typical and normal.
[00:18:30] But this isn't a useful way to get information and it can actually be misleading. It can offer misleading ways to get information about what partners might actually like. It's very misleading on the consent front. And so I think we, and we want to make sure they get alternative information. The older your kid is, the more I would want them to read… certainly younger kids should get have books about puberty and sexuality.
[00:18:52] Hopefully you live in a place where they can also get good sex ed in school, but we know that's not the case everywhere. So we know kids need to be able to talk to their pediatrician and other things. But we need to make sure that they have good information. And then for older kids, like reading a steamy love scene in a young adult or even an adult novel is preferable to me by a lot.
[00:19:12] I mean, there's a lot of books I would want my kid or be comfortable with my kid reading as opposed to seeing pornography. And I think that's really important to make sure that kids do have access to information. And we need to know that it's not just boys looking at porn. Girls will look at it too. A lot of kids are accessing porn for, for sex ed purposes, or that's what they think it is.
[00:19:30] LM: Yeah. And one of the other specific worries I think that comes up for parents of girls in particular, not that boys are immune to this, is the focus on bodies and thinness and diet culture and comparison culture. And I think it's really hard to avoid those, the constant barrage of images of… and now that we have AI where these faces can all of a sudden look perfect and you can see your real face compared to what your face might look like if you had plastic surgery and you were on the red carpet in Hollywood. I mean, that is a pervasive phenomenon and it's concerning as a mother of a daughter and sons, this constant sort of focus on appearance. But again, as I think you're saying, lwe cannot take screens out of their hands.
[00:20:19] We cannot make risk zero. We can do what we can as parents to help our kids kind of have a relationship with screens. So, I was counseling a patient last week who's a mother of a teenage girl who's struggling with her eating. So she's got some binge eating and some restricting behaviors and she's on screens all the time and Focusing on her appearance and the girls, her friends are in bikinis and she's not included in all the events where the girls are wearing bikinis and it's just, you know, it's torture as a mother to watch her daughter kind of go through this and you think to yourself, Gosh, I could just get rid of the screens and everything would be okay.
[00:20:57] Let's acknowledge that wouldn't be the case. And let's acknowledge that's not realistic. So my advice to her was to have a conversation with her daughter that's led with curiosity and empathy. So instead of saying, you really need to get off your screens, that's bad for you, ask the question: “honey, I wonder what it feels like when you're sitting at home and feeling uncomfortable about maybe your body or your social life and you see your friends looking perfect because they've got this curated image of themselves and you're not there. What, I wonder what that feels like.” I mean, and you might offer even an example of what you might feel like. Like it might make me feel awful. You know, when I was a kid and I knew my, my friends were hanging out together and living this so called perfect life, it, it hurt. I wonder what that feels like to you. So curiosity is always a good way to lead a conversation. And then also with empathy and say I just feel bad for you guys that this is such a hard thing to have to navigate. You can't avoid looking at these images.
[00:21:54] You can't avoid comparing yourself to other people. And then sort of open the conversation like that instead of going at it as you really need to get off screens. You need to not look at these images. You need to just stay away from that friend group or stay away from that social media feed. These are their friends.
[00:22:07] These are their lives. But I think it's very hard to know how to have those conversations as parents. And I think the world we live in as parents consuming social media seems to suggest that there's the right way to talk to our kids and the wrong way to talk to our kids. That we have to read the right parenting book.
[00:22:25] We have to follow the right expert on Instagram. We have to listen to the right podcast and that our kids are so fragile and so vulnerable that if we say the wrong thing by just two phrases, then we're doing all this harm when I think that for parents is scary and we need to understand that just by showing up as parents, and just by being empathetic and curious about who our kids are, and showing them that we love them no matter what, that is good enough. Sure, there are parents who are doing harm. Sure, there are parents who need help. I need all the help I can get with parenting, but I also have learned to trust my instincts and intuition, and I need to listen to my kids and meet them where they are.
[00:23:06] There's no parenting book that is going to tell me how to parent child one versus two versus three. So this is a long winded way of asking you, are you saying that parents need to be able to read the room with their kid, they need to be able to understand the person they are talking to, and have a relationship at baseline with their child that involves discussing who they are, what their interests are, and understand that screens are going to be an inevitable part of it.
[00:23:34] DH: I think that empathy and curiosity as you say, is huge and just slowing down, like really saying, what do you notice when you look at Instagram and letting your kid talk. Ideally not even leading with like exclusion or your own feelings, but you can go there and in a conversation, but I would let them what it's like for them and see what insights you can get from there.
[00:23:59] And certainly with body image, as the example you used it can be an exacerbating factor. Like it probably didn't originate with screens, the eating challenges you're talking about, but that doesn't mean that screens couldn't exacerbate. And if a kid is in treatment for an ED, for a substance, for anxiety, for another mental health issue, 100% with that therapist, I would be working on a screen plan with that therapist.
[00:24:25] Especially with a teenager, it's helpful to have someone that's not a parent coming up with, like, if you are going to change the screen plan and your kid is in treatment for an ED or coming home from the hospital even or something. Those are kids who are going to need some support. And sometimes it's apps we don't think of, like Pinterest is actually filled with diet content that is quite toxic.
[00:24:44] If I had a kid with an ED. I would be thinking about, like, how can we encourage them to maybe avoid Pinterest? This may not be a good place for them. If I had a kid who's really into redecorating her bedroom, or a kid who's really into crafting, Pinterest could be fine. So it's not about the app. It's about what experiences and connections and content your kid will seek out within that app. Because I could say the same thing about discord, you know, discord could be totally positive for a kid Who's using it to connect with other anime fans? It could be very negative if kids are doing like how to on an eating disorder or something or self harm. So I don't want to scare people but there are places on the internet and and communities and sub communities that aren't going to be a positive place to be if you're struggling in those ways and asking kids to reflect on their experience, asking kids to consider taking a break.
[00:25:35] Cutting a kid off completely from an app is a pretty big step, but even taking it off your most frequently used device without closing your account can be helpful. And for some kids doing that, even for a few days, just to take that app off your most frequently used device for a weekend and spend a weekend where in order to see that app, you would have to go to your computer and log in.
[00:25:55] I have that suggestion for a lot of kids who are stressing about their grades and actually over checking their grading app. I'll say actually take your grading app off your phone. If you're checking your grading app multiple times during the school day and getting distracted in one class because you saw a test score come in from another class, that's too much. And so some kids are compulsively checking those apps. So I do think in those cases, again, it's not like we never want to see the grading app again. You may need to check it at some point, but like if you have to go to your desktop or your janky school laptop that you don't use that much and check it there, but it's not on your phone, which for 99% of teens is going to be the most frequently used device...
[00:26:32] That's really helpful. So creating those friction moments to make it less automatic and less habitual to go to the places that maybe are kind of death by a thousand paper cuts—maybe it's not like, you know, your phone is hitting you over the head and giving you a substance use disorder and eating disorder, but it's not helping either.
[00:26:51] Maybe that's where change your access. And the more kids feel empowered about that and the more… I talked to several kids who were intentionally following size positive models, people who made them feel good about their bodies. So going in the other direction, using the algorithm intentionally. So for Growing Up In Public, I did talk to some kids who felt like it wasn't great for them.
[00:27:11] And they started using those apps more just for messaging and not posting pictures as much and kind of feeling like they had to post. And again, the people who are curating first, you know, either size positivity or following athletes that they felt like were more body positive and not giving them kind of kicking off or catalyzing feelings that were more negative was so important. But that's a lot of sophistication. Even adults often don't recognize this content is adjacent to this content. But for any kids, I would say fitness content is always going to be adjacent to diet content and diet content is not safe for children. I think it's toxic for all of us, but definitely for kids, you know, if you're looking at your eating or anything with fitness, like talk to your physician. Do not get that from TikTok because it's all very dangerous on there.
[00:27:57] LM: Absolutely. And there's a sort of moralization of human behavior that happens that's just hard not to internalize. I love what you said about suggesting these breaks from screens. I mean, I find it hard as an adult to do that myself, right? When I'm standing in line at the grocery store and it's taking too long, I'm tapping my toe, you know, I'm kind of like scrolling through Instagram to pass the time and it becomes this habitual thing you just go to your phone when you have time to kill and there's a downside there. And so what I sometimes will ask my patients, I will ask myself this too, is what does it feel like internally, and how do you feel sort of mentally and physically when you take a break from, say, Twitter or Instagram for a weekend?
[00:28:38] When you take it off your phone, you don't delete your account, but you take the app off your phone, do you feel less tense in your jaw, less tense in your back? Do you sleep better? Do you find yourself drinking less alcohol because you're less kind of outraged or kind of overstimulated? Do you find yourself gravitating to the book that you put down six months ago? So I think it's not just about restricting the apps. It's about noticing how you feel mentally, physically, how are your behaviors different? If you could give up some apps that you frequently use or gravitate to for a week, what does that feel like?
[00:29:13] So I think what we're talking about really is control. Are we in control of the screens and our utilization, or are they controlling us? It's the same thing I talk about with alcohol.
[00:29:23] DH: I always say that to kids. Yeah, I always say that to…
[00:29:25] LM: It's the same thing I talk about with alcohol, you know, sugar, like, are we deciding how to use it? Or is it deciding for us? And when it is deciding for us when there's a Twitchiness in our brain that gravitates to the phone when you're standing in line at the grocery store or you're lying in bed and you can't fall asleep and you pick up your phone just to kill more time, that may be a sign that is controlling you. And so that's a moment to decide, let's pull back, not because we can't come back into our lives at some point, but let's recalibrate that relationship. Let's put us in the driver's seat of this relationship because it's such a slippery slope, even for grownups.
[00:29:59] DH: Yeah, what I say to kids is you want to be running your devices, not letting them run you. And that's, I absolutely feel that way. And that could be my inbox some days. It's like, wait, I need to set my priorities and not let my inbox set my priorities, right? I need to not just be reacting. I need to be planning and prioritizing and doing things in a way that makes sense like most of us check email too often too frequently throughout the day. So it's really important to talk with kids about that. And when I talk with kids about running our devices and not letting them run us I talk a lot about distraction and even what are the intentional things I do as an adult and as a writer like when I go Speak at schools or is like she wrote books like I'm like, oh, yeah like that's so easy because most kids find writing hard and guess what?
[00:30:38] I do too. I have to give myself rewards for every 500 or 1000 words I write. Like, it's not easy. And if I have to do an edit, which is even a next level challenge, often I will print it out and do it offline because of distraction, because I would much rather check the news or I mean, check the weather or scroll Facebook and see somebody's cute baby, whatever, then do that edit. And so I talked to kids about what do I do to set myself up for success? And when we as parents see our kids going down that rabbit hole, I mean, A) we have to look at how did we spend our time as teenagers? Did we always spend our time in the highest and best way? We did not.
[00:31:14] Like you probably spent some time sleeping very late. You probably spent some time, you know, like I spent time like playing songs on the radio for my friends over the phone. Wasn't like the highest and best use of, you know, our time. Like I wish I had been more like Greta Thunberg. We'd be in a much better place now if my generation had been environmental activists instead of playing songs for each other on the phone.
[00:31:35] But that kind of downtime and like watching a TikTok video with friends isn't necessarily bad for kids. They need some of that. But if you feel like it's a huge rabbit hole for a kid, your kid, and they're losing time that they need on other things like sleep or homework or, you know, any physical activity, chores around the house, Then we can talk to them about how can you choose your time? Especially when you have something with no ending cues, like a TikTok or an Instagram. How can you decide I'm going to do my hardest subject homework first. And then maybe I am going to scroll Instagram for a few minutes. And then I'm going to do another subject.
[00:32:09] And then maybe I will look at TikTok, but I'm going to set a timer on myself. Because there's no end to it. And the algorithm is really good. They're going to give you something you like. Like if they know what you like, they know what you like. They've got your number.
[00:32:21] LM: Yeah, I think at the end of the day, it's incredibly overwhelming, as you know, incredibly stressful for parents to think that we can put our arms around this behemoth of social media. And we really can't. And so I think what you're saying, Devorah, is to know our kids, to have those open lines of communication, to lead with empathy and curiosity for who they are, how they spend their time, what social media means to them, and then to recognize the good of social media, the good, the practice it can offer kids, setting boundaries and setting limits, and where to spend their time. It sounds like you also think that we can kind of tap into their interests.
[00:33:02] If you notice your kid on, you know, baking shows, then hey, maybe it's time to take a cooking class together. I mean, that would be sort of... The dream is that your teenager would want to take a cooking class with you, but I think we can use it as a road.
[00:33:14] DH: Even they could just make dinner. I mean, honestly, like if you're, if your kid is watching cooking shows, like have them make dinner. I want to eat those cupcakes. I want to, you know, eat that homemade pasta and truly like your kid will be the most popular kid on the floor of their dorm if they can make a good meal or even just some nice cookies.
[00:33:30] And so, and, and even if they're watching like how to make slime, like I want to see some slime. Like I don't want endless how to content filtering into a kid's brains without them putting it out. And the other thing we really want them to remember is there's other human beings on the other end. So when they are connecting with kids, those people have feelings too. If you're going to make a snarky comment on somebody's YouTube, that's a real person. And not only is it to that person, but you're also dealing with the people who will read it. So if you can't say something nice, it's not a good thing.
[00:34:00] You don't want to put that out there. And if someone is really bringing about your ire and your rage, and there are people on YouTube that bring, and Twitter and other places, that bring out my rage and my frustration, but my frustration is best channeled finding people I agree with and doing something to solve the problem.
[00:34:14] If somebody's being a racist or misogynist mouthpiece on YouTube, responding to their YouTube with a comment criticizing them isn't going to fix it. They're not going to say, “Oh, well, Devorah in Chicago thinks I should change my ways. I'm having a mea culpa moment. Here I go. I'm going to go down a new road.”
[00:34:31] Instead I want to do, think about like, what can I do in my own community to fight racism? What can I do in my own community to build an accepting school district for LGBT plus students? What can I do in my community to fight misogyny? And make safe spaces for women and girls? So I think it's really important to focus on what we can do to make the world better when we see things that enrage us and not get into like an outrage cycle online. And I think unfortunately that is another thing that the algorithm is really good at is like churning us up in that way. And that's something we want to resist.
[00:35:03] LM: That's right. And being in control of our own emotions. Recognizing that it wants us to be afraid and outraged. Fear and outrage is how they, how the social media algorithms work. So if we can say, look, I'm of course entitled to be afraid. I'm of course entitled to be outraged, but I'm going to calibrate that to my understanding of the facts and not calibrate it to what the social media algorithms are serving up.
[00:35:28] Now that's a tall order for kids. It's a tall order for adults, but I really like what you're saying again, just to frame it is that we as parents need to understand that there's good, there's value in social media. We have to feel that way because it's not going away, but it's true. There is good. There is value.
[00:35:47] In fact, during the pandemic, I was grateful in many ways for social media, for my kids to be able to connect with their peers and classmates, despite being out of school. So let's end with this question. What do you think a healthy relationship with social media looks like? What is the sort of definition of healthy social media habits?
[00:36:06] DH A healthy social media relationship is one where you're using it if you want to, because you want to, and you're getting pleasure and distraction and entertainment from it. You're getting maybe ideas and inspiration from it as well. And you can have a sense of humor about it. You know, everybody's posting about living their best life, because nobody wants to see you unloading the dishwasher.
[00:36:28] But the reality is most people's lives are a lot more about cleaning the cat box and unloading the dishwasher and running around and getting things done or if you're a kid like doing your homework or whatever and that very little of your time is on top of the mountain with the sunset or at the party.
[00:36:43] And so it's good to remember that it's a performance and to just have that sense of humor about it. I mean, I try, even though, of course, like my publisher wants me to be famous and get likes as well. Like I have that pressure as an author and a speaker, but I also have to have a sense of humor about it and say like, okay, this time, I'm not going to do the reel and chase the numbers, or this time I'm going to do it, but I'm going to try not to keep checking my phone to see how many likes I got, because I know that's the app getting me where I'm the most human, where I want to be seen and regarded. And that's where we all are.
[00:37:12] So if we can let our kids know that we have empathy for them, and that we see them, and make sure that they have things that they're doing outside of social media that bring them real self esteem, which is being helpful at home and in the community. to balance out that sense of chasing that algorithm or the numbers or the followers or the likes, I think that's a healthy relationship with social media. So use it for what it's good for.
[00:37:34] LM: I love it. I love it.
[00:37:35] DH: And be able to take some space.
[00:37:38] LM: And as we've talked about earlier, acknowledging that it is. An input, just like food, water, screens are now, you know, sort of part of our sort of nutrition, sometimes good, sometimes bad, but we have to metabolize it and we have to be aware of how it affects our bodies and minds.
[00:37:56] DH When it makes you feel bad, definitely put it away. That's I mean, That's definitely time. When it makes you feel bad, that's the time. If you're watching other people do stuff without you and it's making you feel terrible, put it away.
[00:38:05] LM: So Devorah, thank you so much for joining me today. It's been a pleasure and I've learned a lot.
[00:38:09] DH: Thank you so much. It was great talking with you.
[00:38:16] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
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What gives you meaning and purpose? How do you measure success? What does it mean to be healthy?
Suneel Gupta is helping people grapple with these essential questions.
His new book, Everyday Dharma: The Timeless Art of Finding Joy in What You Do, is about reconciling what we do with who we are. Gupta describes our “dharma” as our calling—or what Gupta’s grandfather called our “essence.” Gupta recognizes the central tension between outward markers of success and finding this internal sense of purpose. A successful entrepreneur and bestselling author, Gupta has also grappled with depression and self-doubt, fueled by the natural tendency to measure success with external metrics instead of asking ourselves the “Why?”
On this episode of Beyond the Prescription, Gupta explores the harms of hyper-vigilance and the power of vulnerability. They discuss the “Arrival Fallacy,” the false assumption that once you reach a goal, you will experience enduring happiness. He shares parts of his own process of self-discovery that allowed him to pursue his inner purpose and help others do the same.
Join Dr. McBride every other Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. My guest today is the ever dynamic. Suneel Gupta, who's passionate about helping people achieve success in a healthy, sustainable way. Suneel is a beloved speaker, a visiting scholar at Harvard Medical School, and best selling author of two books. His new book is just out. It's called, Everyday Dharma: The Timeless Art of Finding Joy in What You Do. It's really a practical guide to finding your dharma, your inner calling, and learning to integrate ambition, work, and well being to create a balanced life. The book combines Suneel's own stories with history science, Eastern philosophy, and Western methods. Suneel, thank you so much for joining me on the podcast today.
[00:01:49] Suneel Gupta: Oh, Lucy, I'm so glad we were introduced and it's good to be here.
[00:01:52] LM: So let's talk about Dharma. There's something about it that resonates with me as a physician who's in the constant quest tohelp patients pull the curtain back on their story. So what is Dharma?
[00:02:04] SG: Yeah, I mean, I wrote this book really for the same reason. I think that we are experiencing an overwhelming sense of emptiness right now and society sort of speeding up. All right, we're using artificial intelligence, we're using automation to continue getting faster and more productive. But I think as individuals, we're kind of in a lot of ways moving in the opposite direction.
[00:02:28] We are starting to feel like we are disassociating with our work, we are quietly quitting. And I think the result of all of it is that we are losing an emotional connection to what we do, which I think is a shame because we spend so much of our time either at a job or with the work that we do.
[00:02:45] And to not feel that connection is, I think, I think it's devastating, right? It causes, I think, a lot of the symptoms that you talk about on this show. And so the reason that I wrote this book is because I wanted to to talk about how do we bring that emotional connection back to our work in a way that really feels real to us? And dharma is an age old philosophy really about that connection and one of the underpinnings of dharma is that while it may be tempting sometimes to try to find happiness and bliss outside of your work, there also is another path which is finding it through your work, right?
[00:03:22] And Dharma is really the alignment of who you are and what you do, because when those two things are lined up, you feel creative, you feel energized. My grandfather called this your essence, right? And when you are expressing that essence, you're lit up, you're energized. But when you're not, you feel depleted, you feel burnt out.
[00:03:43] And so I think the question for us is, how do we now start to come back to this essence, right? And it's something that's available to I think all of us. It's not the kind of thing that you get to luxuriate about when you've hit a certain level of status or wealth. I think it's it's available to every single one of us no matter where we are in our career the the challenge though is that most of us don't know what our Dharma is and even if we do understand to a certain degree, what our Dharma is, what our inner calling is, we don't necessarily feel like we have the time or the space or the money sometimes, or even the courage to pursue it. And I wanted to write this book because I wanted to go directly into those struggles. Not to write a book about what purpose is sitting behind a desk, but how do you take this thing that you feel that you need to express, right, it needs to speak, and how do you once and for all start to bring that into your everyday life?
[00:04:39] LM: I love that I commonly talk with patients about this gap that exists in all of us between our best intentions and the execution of them. Meaning, like, we know we want to eat healthy. We want to exercise. We want to be more purposeful. We want to be more intentional. We want to put our phones down. We want to be happy and pursue things that are joyful, but there's that gap and the river is wide between the intentions and the execution. And you just said it, Suneel, sometimes the gap is filled with financial insecurity. Sometimes it's filled with logistical obstacles. Sometimes it's filled though, with fear and maybe even ambivalence, and then maybe even not knowing what your purpose is. So talk to me about how you might mind the gap. Those are my words, but how you kind of actualize and take control over your sort of sense of purpose and meaning.
[00:05:37] SG: Yeah. So two different things that come together, right? Who I am and what I do, right? And I think the what I do is the execution. Who I am is really sort of getting into like, what it is I care about. Let's start with who I am because I think that's just a natural place where I think a lot of us, I think me, me included would skip over. And the reason I would skip it over is because I would look to what everybody else sort of had, right? I would look to people I saw with nice cars and nice homes and really nice sounding LinkedIn profiles and bios. And I'd say, let me go follow that. And what I found over time is that I was really walking somebody else's path, not my own.
[00:06:12] And I think the work to sort of coming back to yourself and understanding what you want, it doesn't have to be something that you go on a huge meditation retreat. to do, right? I think it comes through starting to ask yourself certain questions. And in the book, I go through a list of sort of questions that really sort of helped me kind of get to this point.
[00:06:31] I call these the chisels. And the reason I call these the chisels is because Michelangelo, when he would look at a block of marble, he would say the sculpture is already inside. All I have to do is chisel away the layers. I don't have to create something from the ground up. And I think dharma, or calling, is very much the same thing.
[00:06:48] I bet that at some point in time, you have experienced your dharma. Like, you have lived up in a certain way. It may have been when you were a child. It may have been last week. It may be something that you're actively doing even at your job right now, but you're just not, you're not in tune with that.
[00:07:03] You're not in touch with that. So what I think of one of the very first things that we can start to do is start to identify the bright spots, whether that be in a past role or in a current role, these moments that really made us come alive. I think the key here that I think that we sometimes miss, I know I did, was that when we think about things like purpose and dharma, we think about a job.
[00:07:23] And so like in the book, for example, I tell the story of a woman named Mila, who really wanted to be a teacher. She was a project manager, but she really wanted to be a teacher, right? And she was frustrated because she couldn't, like, realistically, she had kids, her family relied on her health benefits, like the idea of leaving her job, going back and getting a teaching certificate was just not something that fit her practical life.
[00:07:46] And she was frustrated by that. And I think a lot of people sort of find themselves in a similar position. But when she was able to peel back the layers and understand, well, what is it about teaching that I love, right? When I dig below the occupation and into the essence of teaching, what ultimately arrived for her was that she loved to help people grow.
[00:08:05] And there was this emotional conversation she had with her mom, where her mom's like, Yeah, you've always loved helping people grow. Ever since you were a little kid, you were the kid who helped the kids on the other, on the block, like, learn how to ride bikes. It's the thing that's always been a part of you.
[00:08:19] And once she sort of reconnected with that essence, all of a sudden, all these different ways of expressing that began to open up for her, right? Teaching was obviously one of them, but she could start to coach people at work. She could step into a lateral shift into HR and start growing people inside the company.
[00:08:35] And all these options started to pop up for her. When that happens, Lucy, it's liberating because how many of us right now are like, Oh my God, like if I just took that other fork in the road in my career, then I would have ended in this job that would have been perfect for me right now. And I would be so much happier.
[00:08:52] Well, the reality is that over 90% of us right now are looking for jobs, right? In 2023. Over 90% of us right now are looking for our next job, and what the data almost overwhelmingly shows is that we're going to jump to the next job, and within a few months, we're going to feel exactly the way we feel right now, right?
[00:09:09] So I think with Dharma, with who I am, we're peeling underneath the occupation layer, and we're going into the essence layer. When you tap into that essence, you can start to figure out how to express that, and your world kind of opens up.
[00:09:21] LM: It's amazing the way you describe it. I love the Michelangelo image, right? The block. And he says, I'm just repeating it back to you, but he says the sculpture is already there. It's just that you have to pull back the layers and that's exactly right. I think when people are able to do that, as you've described in your book.
[00:09:40] LM: To me, that's the definition of health. I mean, health also includes having nice cholesterol levels, not having a heart attack, doing your cancer screenings, but health at its core is about awareness of our stories and how they live in our bodies, awareness of medical data, our own data, and the way our data is contextualized in the literature and then accepting the things we can't control, so other people, our genetic predisposition to breast cancer, and then finding agency where we can, because we can't control other people. We can't control certain genetic predispositions. We can't control the fact that we may be financially bound to stick with a job we're not fully actualized in, but people often have more control than they think.
[00:10:28] And I think what you're saying, Suneel, is that part of the control and the agency we have, which is ultimately. To me, a part of definition of health is simply querying our own bodies and minds and asking ourselves, like, what is my passion? What am I here for? How do I feel when I'm doing something that gives me joy? And can I recreate that in other spheres of my life, whether it's at work or parenting and ultimately that feeds back onto our health. I mean…
[00:10:55] SG: It does.
[00:10:56] LM: During the pandemic, for example, I saw people every day who were experiencing physical manifestations of emotional distress. And some of it was burnout from caring, caregiving and parenting and living through a pandemic, just being a human.
[00:11:08] But even now, I mean, people are wired and tired and they don't feel well. And so it's reassuring to me to hear someone like you talk about, to me, what is really the essence of health in your book.
[00:11:24] SG: Dr. Tal Ben-Shahar, who you may have crossed paths with at Harvard, really sort of, I think, Explains this nicely, which is like he has this phrase called the arrival fallacy and the arrival fallacy is basically this idea that like we're going to hit this moment where we've attained enough wealth, enough status in order to feel this lasting sense of joy on the inside.
[00:11:47] And until then, we're willing to suffer. Until then, we're willing to sort of grit it out, grind it out, do whatever we need to do because we believe we're going to hit this moment where it's all going to have been worth it. And at some point in time, I think we all get wiser to this idea right? And I would argue that We're starting to realize that earlier in our lives.
[00:12:05] I think Gen Z is asking difficult questions that older generations sometimes don't like because they're like we didn't ask those questions when we were your age, right? And they're, I think, very understandably saying, yeah, but you don't seem very happy. And we want to do things a little differently than you.
[00:12:20] I mean, the country has gotten richer, we've become more productive, but we're also more lonely than ever before. Mental health issues have never been higher, right? We feel disconnected from one another. That's not necessarily sort of the train that I want to get on. And so to ask the difficult questions right now, and to your point, to be inside out about it, right, to peel back the layers, I think it's a very reasonable thing. And then the question I think becomes, well, then once I start to peel back those layers, how do I actually put it into practice, right? Because there's nothing more frustrating than understanding who you are, but showing up every day and feeling like you're walking in somebody else's path.
[00:12:55] And what I try to do in the book is really get into those struggles again, like we may not feel like we have enough time. We may not feel like we have enough money. We may feel like we know exactly what it is, but we're scared of that. And so I wanted to tell like the everyday stories of people who were able to not necessarily even leave their jobs.
[00:13:14] Like one of my favorite stories in the book is, is about a nurse who really wanted to be a writer. And her parents said, no, you can't be a writer. You're first of all, writing is not a profession. It's going to make money. You're not a, you're not a man, right? Like, and, and like, if you're a son, if you're a son, maybe, but like, as the daughter, no, you're not going to be a writer.
[00:13:31] And so she got pushed into a different field and became an outstanding nurse. But one of the things that she realized is that she was able to bring her persona as a writer into her work of nursing. And one of the ways that she did that, it was through her patient paperwork. So, while most people like, try to get through, and you know this Lucy, try to get through the paperwork as quickly as possible, like put the clinical details in, she started to actually expand on those clinical details into like, who were these people?
[00:13:56] What did they care about? Who do they love? What was their life like at home? What was their experience of being a human like? And she would start to pour her heart as a writer into these clinical patient forms to the point that like literally this paperwork was getting passed around the hospital like novels people loved reading it because it gave them a sense of purpose and what they were doing and so she was able to express this dharma as a writer through her occupation as a nurse and the point of it all is that oftentimes we think that in order to live our purpose we have to blow up our lives. We have to leave our jobs, right?
[00:14:30] We have to move to a different place and become a painter or leave everything we have behind. Not true. And there's so many situations and stories in the book. We talk about sort of how Dharma doesn't have to be a separate path, but it can be a permutation of what you have right now. You don't have to leave everything behind. You can start to bring a new persona into where you are today.
[00:14:49] LM: I love that Suneel, I think you're right that life happens in the mundane in a way, right? It's not in the big sort of huge moments. It's really in the everyday moments that sometimes we don't even know exist. It's just a tuning to the present. How did you get to be so wise? I mean, you're young and you talk a lot about burnout and failure.
[00:15:12] I love that story you told about. You told your wife, I'm a failure and she's like, no, you're not a failure. And you're like, well, the New York Times says I'm a failure. And then you showed her the article about your talk about failure. And so like, what is your story? How did you get to the place where you are now writing and speaking and talking about these very soulful topics?
[00:15:36] SG: Yeah, I mean, I think success is a lousy teacher, there's no doubt about that. It's wonderful, I'm not trying to downplay success, like, I think that I've had some success in my life and has been able to provide the sort of, I think, a life for my family, it's allowed me to sort of take care of my kids, and I'm very thankful for that.
[00:15:54] And yet, if I look back at sort of where the learning really came, where the growth really came, it didn't come from success, it came from setbacks, it came from mistakes. It came from change when I coach sort of organizations and leaders today, and I asked them, what was the most important part of your career, right? Most important year of your career. Very rarely do they say like it was the winning year when I had the most profit or it was when I earned the biggest salary. Most of the time it's like something big happened, it was a big change and usually that change isn't positive. It's like it was something that got knocked back on their ass and they had to sort of learn and that changed everything for them.
[00:16:32] But that was really meaningful. And I think I've had no shortage of I think those moments where I felt like I wanted something really badly and I put myself out there and it didn't happen. I think the learning for me, though, sort of came from sitting down and writing about that. Right? So, I think, if I'm being honest, like, I started writing because I was depressed.
[00:16:55] I was feeling anxious. And I realized that I was dumping a lot of that on my wife. I was spending a lot of time talking to her about that, and I realized, and as, like, loving as, like, Lena is, I realized it was unfair for her. She was always listening, but it was unfair to just, like, almost, like, vomit my trauma on her.
[00:17:13] And so I started to use the page, right? Literally sit down at my desk every morning and I started to write about these things that I felt like I was struggling with and searching for answers to that would do it every morning because the page always listened, no matter what it just listened. And I'd say 99% of what I've written in my life has ended up in like a trash bin, nut there were some pearls there were some little pearls that was able to string together along the way and eventually those pearls started becoming blog posts that became published articles. Eventually they became books and that's just kind of the thing like I think if you look hard enough There are these poor these pearls of wisdom.
[00:17:55] I talk about this a lot in the book is like I think I was following sort of an outlook of resilience before right and now I feel like I'm following an outlook of growth and the difference between the two is that like with resilience, there can be a tendency sometimes to just like want to get back up right like pull yourself up by the bootstrap, let's get back up. But I think growth is getting back up, but also taking some time to understand. What did I learn. If my kid was in a similar situation? Well, how would I sort of help coach them through a situation like this? What would they learn from my mistakes? Taking such a taken like a reflective view on that.
[00:18:35] Even just spending some time moments, right, to write about it, to learn about it, even if it's just for your benefit. Nothing you're gonna publish, but just something that you're gonna reflect on yourself I think can be the difference between cycling through the same mistake over and over again, and I think actually using a setback to create genuine.
[00:18:56] LM: I love that. I have a comment and then a question. The comment is about the writing. Like you, I find writing to be very therapeutic. I find that I can really crystallize a lot of my thoughts. I mean, writing ultimately is about thinking. And when you're putting things on the page, it's clarifying to oneself about how you're thinking.
[00:19:17] It also can disarm some sort of scary thoughts. I have found, like, when I've had depression symptoms or I've been anxious, when I journaled, I was a journaler from a young age. Just intuitively, I knew to write. When you look at the words, A day or two later, you realize that with time and with perspective, they're not so terrifying.
[00:19:37] And so, I too find writing really therapeutic and I recommend it commonly to patients who are experiencing depression or anxiety or trauma as an adjunct to other sort of treatment modalities, but certainly kind of writing down our thoughts can help disarm them.
[00:19:52] SG: Yeah. One of my favorite techniques is to write what I call sort of the if true, then pattern.
[00:19:58] LM: Tell me about that.
[00:19:59] SG: going a little bit deeper into the fear can be a really illuminating thing. So if I'm scared that I'm going to blow a presentation, right, I'll write that down. Like that's the thought inside my head, you're going to blow this presentation.
[00:20:12] And then I kind of talk with the fear. I say, okay, let's pretend that happens. If true, then what? And then it's, you're not going to get the deal or you're not going to get the, you're not going to get the job or whatever it is. Right. And they say, if that's true, then what? Well, then you're, you're not going to have this role that you wanted.
[00:20:27] If that's true, then what? Well, then you're going to blow up your career. And if that's true, then what? And I continue to just sort of go deeper down. And when it starts to make me realize is that underneath this surface level fear, all these sort of deep seated concerns that almost in all probability will not come to happen, but the other thing is that at the very bottom of that list Right when I really dig down to the root of it It always ends with something like well your wife is no longer going to love you, your kids are no longer gonna love you, right?
[00:20:59] And I think to myself Wow, that's the deepest root of my fear and I actually have more control over that right now Then I do whether I get this presentation done like I can go give my kids a hug I can go tell my wife I love her. I can do that right now. What happens inside that presentation, I don't know. But I know the deepest fear, I can deal with right now.
[00:21:21] LM: It's such a powerful point, Suneel, because I think all of us have at our core, the fear of not being loved or being worthy. Like shame and feeling excluded or not loved are like the deepest fears. And I think a lot of those fears come up in our childhood naturally, right? Like I think of life as this set of experiences and we're like a blank canvas when we're born and then you experience loss and challenge and hardship and dings on your self esteem.
[00:21:57] And then we create this sort of network of connections in our minds. In fact, we call it the default mode network. It's a set of neural pathways in the front of our brains that basically are derived from a lot of pattern recognition so that we don't reinvent the wheel every time we come across a new scenario, right? Like, we lose that wonder and curiosity of childhood.
[00:22:20] But we also gain some street smarts, but the downside of that default mode network in the front of our brains is that we can start to make assumptions about things and make connections and thought and behavioral patterns that actually aren't serving us at the time. In other words, you can have an experience as a child where you were terrified and felt vulnerable.
[00:22:41] Maybe you weren't picked for the team or something. And then you wrote a story in your mind about why. And then the next time something happens to you that's like that, even in your adulthood, you might then go back to that sort of I'm not worthy narrative. So, this is a long way of asking you, about your childhood.
[00:22:59] And now we're going to do like go deep here. Like, I love that pinned tweet on your Twitter feed. I guess it's called X now, about your mom. And I'm like, okay, there's a story there. First of all, her story and then your story of her being your mother. Someone says to her, “go back to your country.” And she says, this is my country.
[00:23:17] And then I think the man says, get out of my kitchen. She says, this is my kitchen. And then there she is in all of her glory on time magazine, telling her story. Tell me about like growing up in your family. What was her story? How did that affect your story? And then your telling of it to yourself and then the experience of fear and vulnerability, like you just described,
[00:23:37] SG: So, mom grew up on the border of India and Pakistan, right? When it was all one big country, when it was India. When the country split, during partition, was one of the bloodiest conflicts that humanity has ever known and she was part of that. She was in, she was right in the mix of it and their family fled.
[00:23:56] She ended up in a refugee camp as a kid, very little running water, no electricity, but she decided that she was going to teach herself how to read. And she felt like that was going to be sort of her path out of poverty. And so she did. And she knew she had enough foresight even back then to know that like English was sort of the language that she would have to learn if she wanted to get herself to the United States because that was her dream. And so she started reading and the first book that she read from cover to cover was a story about Ford Motor Company because Ford Motor Company was literally the Google of its day.
[00:24:30] The big, it was the big company. Everybody knew about it, right? If you were rich and you were driving sort of a Ford car, even around sort of certain parts of India and she would see that and that's what she wanted. And she wanted to be an engineer, as well, and she set her heart on that, and it was a very unlikely dream because people from her country, especially women, that period of time were destined for the kitchen, right?
[00:24:53] And I mean, the best case scenario for her as told to her by some of the other people in her village was Find a rich man, find a wealthier man, somebody who isn't in poverty, and that's your path out. She wanted more, like she wanted to express herself. And so she studied hard and people got behind her, her parents got behind her, they saved every rupee that they had.
[00:25:13] She was able to get on a boat to eventually the United States. She got a scholarship to Oklahoma State University. The day after she graduates, she finds herself to Detroit, Michigan. She applies for her dream job. There's a lot there. There's another story there. But she gets it. And in 1967, the reason Time Magazine wrote about her is because she became Ford Motor Company's first female engineer.
[00:25:34] Ford Motor Company had thousands of engineers on staff at that point in time. Not a single one of them was a woman. And so here she is, this woman who tends to dress in saris, and she cooks and eats mainly Indian food back at home, and she is now amongst this, like, sea of mainly white men who are doing this job, and she finds a way to sort of fit in, or I shouldn't even say finds a way to fit in, she finds a way to be herself in a very different environment.
[00:25:58] And, and I think that for me as a kid growing up in almost the opposite situation. I'm an Indian kid now growing up in America. I live in suburban Michigan. Everything is compared to my mom. We lived in a pretty, we lived in a three bedroom house, but like it was a night and day difference from the conditions that she grew up in.
[00:26:17] It was the equivalent of a silver spoon in my mouth and the fact that I could eat every single night. I think that for me, what. I've learned about my mom and what I've learned about, I think other leaders who I spend time studying and I think admiring who have done difficult things is I think that the thing that holds a lot of us back are the words, “I'm not ready.”
[00:26:40] Right? Like, I'm not ready to, to run with that thing. I'm not ready to step into that role. I'm not ready to speak my mind. I'm not ready. And I think the confusion sometimes is in believing that the people who did difficult things, my mom included, is that they were somehow ready to do what they did, but they weren't, right?
[00:27:01] I call this the game of now, in my book, versus the game of someday, right? The game of someday is you wait for courage. You summon up enough courage, and once you actually have enough courage, you take action. And I think that's the way that most of us behave. There is another game, and that's the game of now, which is that instead of waiting for courage in order to take action, you just take action, and you let courage catch up along the way.
[00:27:27] And I think the thing that I've learned is that it almost always does. If you just say like I'm gonna go do that thing courage will come even begrudgingly courage will be like, okay. I'm with you, right? That's the thing I learned about her story is that it wasn't the story of a little girl in a refugee camp who said f*ck it all I'm gonna go do this thing. It was more a story of a scared person who said I want this really badly and I'm scared And I'm going to do it anyway.
[00:27:58] LM: that is a huge lesson. And I wonder how she expressed that. I mean, you told me in so many words, but like. Did she talk about like the lack of courage? Did she talk about her fear and just doing it despite having the courage or did she just model it? Was it the kind of thing you talked about as a kid?
[00:28:17] SG: Not as a kid, no. I think as a kid, I had very surface level conversations with my mom. I marveled at her story, I marveled at who she was, but I didn't really dig into the how. If there's anything that I felt as a kid, I felt like kind of almost insecure because here was a parent and I have a brother who's done amazing things as well and my father's an immigrant too.
[00:28:40] And so I sort of, I felt like I kind of came from this really brave family and I felt insecure because I actually didn't feel all that brave. I just didn't. And, and that made me feel bad because it was just, I felt like, wow, like, gosh, I'm surrounded by all these incredibly courageous people and I'm not one of them.
[00:28:58] But. I began to realize over time, more from the stories that I would dig into, more from hearing about what it was like at Oklahoma State University when she was sitting in her dorm alone, right? What was that sort of like for her because she didn't eat meat and she couldn't go to the cafeteria because she was a vegetarian?
[00:29:17] What was that like for her? And I think when you dig into people's stories and you get beyond this happened and this happened and you just simply start to ask the question of like, what was that like for you? And that's when you start to get insights, but I didn't start asking those questions until I was a teenager or maybe even in college when I would come home and have conversations with her.
[00:29:35] And the thing about it, Lucy is like, I love that question now. Like I host a documentary series where I travel around the world and I meet with all these leaders who've done crazy things. And I almost always dig into less of what they did, but what were they feeling in those moments along the way?
[00:29:54] LM: It's the essence of who people are. Right? Suneel, I can't thank you enough for joining me on the podcast. You are such a bright light and I can't wait to share your book more widely and to reread it. And I just thank you so much for your pearls of wisdom and for acknowledging that you're a work in progress too.
[00:30:13] I think that we're never done. We're never done in the process of self discovery and then bringing our best selves to our relationships, to our work. And so I appreciate the humility that you offer as well. So thank you.
[00:30:26] SG: Thanks, Lucy. It's so good to be here.
[00:30:35] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it, and if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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Confused about how to handle COVID this fall and winter? Wondering how to think about masks, boosters, and reducing your risk of getting sick?
On this episode of Beyond the Prescription, Dr. McBride talks with Monica Gandhi, MD, MPH, who became one of the most prominent public health experts in the country during the pandemic. Dr. Gandhi is a Harvard-trained physician, expert in infectious diseases, and professor of medicine at the University of California, San Francisco (UCSF). She is the director of the UCSF’s AIDS Research Center and the medical director of the San Francisco General Hospital HIV Clinic.
Dr. Gandhi’s career centers on the principle of harm reduction, born out of her decades-long work in HIV. Harm reduction is the belief that public health policies should consider not only the pathogen (i.e., HIV or COVID) but also people’s basic needs for social connection, intimacy, and agency—and that public health’s job isn’t to shame, stigmatize, or even to eliminate risk (that’s impossible) but rather to arm people with information and tools to mitigate the inevitable risks we face.
Her new book, Endemic: A Post-Pandemic playbook, published in July 2023, aims to reckon with the country's present condition: comprehending and living with a new respiratory disease and how to face the coming variants and next pandemic with reason, science, courage and compassion.
Listen to hear Drs. Gandhi and McBride discuss where we have been, where we find ourselves now, and how we ought to manage the virus this season, and in the coming years.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
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The transcript of our conversation is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go beyond the prescription. Let's talk about Covid. Joining me today is my dear friend, Dr. Monica Gandhi. Monica is a physician and professor of medicine at the University of California, San Francisco. She's the director of the UCSF AIDS Research Center and the medical director of the San Francisco General Hospital HIV clinic.
[00:01:21] She studied at Harvard Medical School and then at UCSF where she focused on infectious diseases, specifically HIV. She holds a master's in public health from UC Berkeley, with a focus on epidemiology and biostats. During the pandemic, Monica became one of the most prominent public health experts in the country.
[00:01:42] National and local political leaders, medical professionals, and the media often turn to Monica for her thoughts and recommendations on how to handle the constantly shifting dynamics and demands of COVID. She has now put her thoughts together in a new book, Endemic: A post pandemic playbook out in July 2023.
[00:02:02] It aims at reckoning with the country's present condition, comprehending and living with a new respiratory disease back in 2020, and how to face the coming variants and the next pandemic with reason, science, courage and compassion. Monica is not only an accomplished physician and public health star, she's also a dear friend.
[00:02:24] I got to know Monica during the pandemic when I started noticing that patients were suffering not only from COVID, but also from the sustained fear, anxiety and social isolation of the pandemic. I was immediately drawn to her straight talking, evidence based and compassionate voice.
[00:02:42] It was a rarity in a sea of COVID experts. She seemed to consider the whole patient, to value the importance of human connection as much as guarding against an infectious disease. So we became fast friends. We've written op eds together. And we started a group text of seven women in medicine and public health who now have communicated multiple times a day for over two years today, Monica and I will discuss where we have been, where we find ourselves now and how we ought to manage this virus this fall and in the coming years, Monica, it is so fun to have you on the show today. Thank you for joining me.
[00:03:21] Dr. Monica Gandhi: Thank you so much. It's so good to see you.
[00:03:23] LM: So tell me about your book, let's start there. What are the lessons learned and then how can we move forward with COVID in our midst in perpetuity and the potential for new viruses coming along? So tell me about the book and what are the major themes in the book?
[00:03:40] MG: Yeah, so thank you. It starts out with an introduction to the concept of why I was so interested in infectious disease and I went into it and that really had to do with my interest in HIV, even from a very young age, my interest in social justice, my interest in disparities, and my interest in the fact that people are stigmatized for infectious diseases, which I always found completely shocking in the world of HIV.
[00:04:04] It's kind of Lehman's language on the whole pandemic and where we are with vaccines and therapeutics. And then it goes into harm reduction. And what that means is really that you have a pathogen. Let's say we had HIV which we did and we still do. And the way that we dealt with HIV, at least those people who are expected dealt with HIV is they dealt with this kind of whole person aspect of care.
[00:04:29] So you have a person living with HIV, but you also have their mental health and their sexual needs and their needs for companionship and their needs to have hope and it to become an HIV doctor became a really, I think, a doctor that sees the whole person and doesn't just see the disease or the pathogen or just the virus.
[00:04:51] And what I saw with COVID 19 is that we used the same bad stigmatizing language that we used with HIV with COVID. There were actually public health people that said, COVID idiot, or you're a bad person for getting COVID, which I still will never understand. And then I thought of harm reduction. What are the ways that we can absolutely fight the pathogen?
[00:05:12] In my mind, it's biomedical advances, but also minimize the harm done to society. And the three I think, or supposed mitigation, because I don't think they helped, that did harm, in my opinion, were prolonged school closures, were closing other medical care, not taking care of other medical needs, especially mental health, and then third is not letting people see their family members in the hospital.
[00:05:36] I think that's actually, frankly, inhuman. So I dwell on those for some time, chapter five is all school closures, then the subsequent chapters on around global equity, because if biomedical advances are your way out of a pandemic, you need to give them to everyone. And then the last chapter is a 10 point pandemic playbook.
[00:05:54] How do we go forward. If this happens again, and I hope it doesn't for 100 years and not get to this point where we are now, where there's about a 30% trust in public health. By the latest poll, a health affairs paper showed that in March of 2023, 30% of people trust the CDC. I mean, there must have been mistakes made for such a low number of trust.
[00:06:14] I don't subscribe to the view that Americans are anti science. I think they saw all the confusion. They saw the harm and they don't trust. And how do we get to a pandemic playbook that makes sense, that takes other people's needs into account, societal needs into account, outside is safer, therapeutics, vaccines. And then we're in the building of trust phase and we can go into that.
[00:06:36] LM: Yeah, harm reduction makes sense on a population level. It also makes sense on an individual person level, just for people who are listening and you don't know what that exactly means. It's rooted in the idea that risk is everywhere, that being a human being involves risk by being in relationships, by driving a car, by existing with bacteria and viruses, merely being a human carries occupational risk.
[00:07:08] And we cannot make risk zero. In the case of HIV, correct me if I'm wrong, the message never should have been abstinence only. Because what abstinence only as a message does... is it deprives people of their basic biological needs to have sex and intimate relationships, and it stigmatizes the person for having human needs.
[00:07:33] So, Harm Reduction's message to HIV patients and populations is, let's not tell you no, let's tell you here are the risks, let's arm you with facts and nuanced information, and give you the tools. Condoms, education, and a way to frame risk so that you can make your own decisions based on your risk tolerance, which you're entitled to.
[00:07:58] You can be very afraid of HIV and never have sex, and that's Up to you, you can be less afraid, but as long as you're aware of the data, you're talking to your partner, then you do you. So I think what I saw in my practice was people suffering from being shamed for going to their child's graduation, even after they'd been vaccinated.
[00:08:24] You remember those pictures of people. On beaches and media pundits were shaming them for being outside when we knew from get go that outdoors was pretty darn safe. And we know that people need to be outside. So somehow we lost the plot and we of course cared about death and dying from COVID, like that is a given, right?
[00:08:47] There's no question that human tragedy. I mean, zero question, but somehow people started moralizing human behavior. And then, if you spoke out, like you and I did, about trying to balance the harms of the virus with the harms of not living a life that is just meeting basic biological needs, somehow if you're talking about that, you're morally reprehensible.
[00:09:15] So, it's a really weird time in our country. I don't need to say that to you, but I just wonder, what do you think is that in inherent tension? Like, where does that come from? That this concept that like doing things, living your life, even if you've been vaccinated is morally reprehensible. I just don't understand.
[00:09:37] MG: Yeah, I didn't understand it until I really went back to the history of HIV, and then I think I made a connection, which is that in the history of HIV, 1981 was when these case reports were first described in the CDC, MMWR, and the President of the United States of, at the time was Ronald Reagan. And because of that, he and his wife also with Just Say No as a campaign for addiction, pushed an abstinence only approach.
[00:10:03] He actually didn't even talk about HIV until 1985. And there was a very like, just say no, there's just something wrong with you if you want these needs. And so the public health community. who tends to be left, as I am, completely pushed against that and said, no, that is a absence based only is an awful approach.
[00:10:22] And it's really unkind and not compassionate. And we can't tell people what to do. And instead we'll give you tools to stay safe. And we'll tell you about condoms and later prep and treatment, but really like it is up to you. You are a human being with your own needs, like you said, in your own risk tolerances and what happened during COVID, as Trump was president, so the public health establishment who's left, and so are ID doctors. They pushed against him no matter what he said, even when it was reasonable, like prolonged school closures weren't happening in Scandinavia and Europe. And he said, let's open schools in summer of 2020. And then people were all writing about opening schools, public health officials, and then they changed their mind when he said that.
[00:11:02] So I think it is actually a push against, it was not reasonable because it was clearly A reactionary pose against the right. And the problem with that reactionary poses at harm children. And it was completely topsy turvy from what we did with HIV. And I think there were two other reasons. One is the media thought that would with a lot of fear, they thought that would kind of scare people into compliance with masks or public health measures. But the problem with that is fear doesn't work. It makes people like paralyzed. I mean, that's what it does in nature. And so it doesn't make you say, oh, I completely understand that even though we have vaccines, they're still telling me to socially distance, even though Europe's gone back to normal with the vaccines.
[00:11:48] Instead of understanding that again, distrust came. And then I think that the third was that we just didn't celebrate the vaccines and no physician is really against vaccines in general. Like it's just a degrading 96% of physicians got vaccinated for COVID with the first two shots. Boosters I think have to be nuanced, but it was a celebration of the vaccine of the HIV therapies in 1990s and with the vaccines. At least the media still made it seem like it was really negative and that didn't unlock the key to normal life, but they didn't do that in Europe. They did. They unlocked the key to normal life. I don't know where anyone thought that normalcy wasn't an important human need, like being connected, being together, joy.
[00:12:37] Being around people, celebrations, church, synagogue, temple, these are part of the rituals of human existence. They're so terribly important for our mental health. So when the vaccines came we could have really celebrated them and instead there's been so much fear still.
[00:12:53] LM: And it's so funny how anti vax, like true anti vax sentiment, people who are saying that the vaccine, you know, alters your DNA and, you know, turns you into an alien, that messaging almost touched the messaging of let's have a vaccine that's life saving in some high risk populations, but it's not enough.
[00:13:15] Let's continue to mask and distance. It almost felt anti vax, as you just said, for me, the moment, I mean, there are many moments during the pandemic when I thought, golly, Baba, we are not messaging this Right, was Provincetown. So Provincetown was that weekend when it was rainy and cold up in Provincetown, Mass. There was a lot of people in intimate settings, post vaccine, and a lot of people got COVID. But no one died. A lot of people got colds, flus. To me, that should have been the CDC's moment to say, “Oh my gosh, this was the stress test for the vaccine. These people have been vaccinated, they got together, they had sex, they had fun.
[00:13:58] And they got colds. And they got flus and that's terrible and we don't want that.” But you know, what are you gonna do? And we should have said, “that's a vaccine success story.” But instead, that's when the CDC said, “nope, put masks back on. And that's when, among other moments where I thought, oh my gosh, we've lost the plot because we're moving the goalpost.”
[00:14:17] It's like kicking a soccer ball down the field and you're, you shoot for the goal and then the goal gets moved. And again, just to be clear to people who are listening, this is not to say, go get COVID, And you know, who cares? Not at all. We can do two things at once. We can be mindful of our risks for a virus and arm people with tools and information.
[00:14:38] We can also be mindful of the risks of living in a state of hypervigilance and fear where we aren't allowed to be ourselves and be in relationships and go to school and see the faces of our teachers. Like, we can do hard things. We can do many things at once. And I think it was this sort of paternalism from public health institutions, it felt very draconian and sort of condescending like that we know better when the vast majority of people who got COVID particularly after the vaccine did extraordinarily well.
[00:15:07] MG: I mean, I think that the interesting thing about what you just said and where I had a little different twist to the conversation was my history in HIV. And so if you look, people were saying a lot of people around that time was saying the same thing, actually, CDC's moment and they blew it, but I could bring in this concept that HIV.
[00:15:28] We never judged people, or what I mean is the people who judge people, we didn't like those people. We didn't like those public health officials who judged. We thought they were really out of line. And we used a harm reduction pro, in this case, sex approach. And so in the case of COVID, what happened with the Delta variant surge in Iceland is the Iceland prime minister came out and said, Look what's happening, everyone.
[00:15:55] You all got vaccinated, the hospitalizations are extremely low. This means the vaccines work. Go back, go forth, be with one another. This is an excellent example of how the vaccines work. And then everyone got vaccinated and the appropriate people got boosted, like older people, and everyone moved on. And they really did move on in Europe.
[00:16:14] So there was this kind of celebration of that moment, and I do write about this in the book. That was, I think, the moment. where the CDC really did lose its trust with the American people and we need to rebuild it, which is a lot of what the latter half of this book is, that the people who are talking right now, like the vaccines and therapeutics don't work are not actually rebuilding trust and certainly not rebuilding trust in technology and advances.
[00:16:42] Like we rebuilt hospitals. Trust in antiretrovirals with HIV to say that life wouldn't change after these advances didn't make sense. This is the other thing that's really important is that beyond bringing the HIV angle to it that I could because I've just thought about it for so long. [00:17:00] It's also important to say that respiratory viruses, cause I live, I'm an infectious disease doctor have always plagued humanity and I worry every winter about respiratory viruses.
[00:17:11] I worry about RSV, and I worry about influenza, and rhinovirus, and other coronaviruses, and adenovirus, and human metapneumovirus. But, actually the difference is, we have better tools for COVID than we do for human metapneumovirus in an older person, for example. I can give Paxilovir to an older person. There are boosters.
[00:17:29] There are no vaccines for human metapneumovirus. There are no treatments for that virus. RSV, we just got a vaccine. So, it means... That we really moved quickly, and we didn't celebrate that, that rapid movement, that incredible biomedical advances. But we did in HIV. We did. We said undetectable equals un-transmittable.
[00:17:49] You don't have to use a condom if you're on antiretroviral therapy. And we were just much more harm reductionist and sitting with the patient, making shared decision making. At least that's what, again, the good HIV doctors were doing. And here it was top down decision making.
[00:18:03] LM: And the MRNA technology that is so incredibly advanced is being deployed now for potential vaccines in HIV.
[00:18:12] MG: it's very exciting. Yes.
[00:18:13] LM: It's very exciting. I mean, I'm with you. Like, you and I got accused, both of us, for spreading hopium. It's so funny
[00:18:22] MG: It's a strange word. Yeah.
[00:18:23] LM: It's such a strange word. Like, you know, but it's sort of the way American medicine addresses patients in general. We think about health as this sort of set of boxes to check. It's about your cholesterol, it's your height, your weight. When hope, joy, and the sense of an end point to a crisis are really important for health. I mean, it's foundational. It's fundamental. The other thing is that hope and caution are not mutually exclusive.
[00:18:50] You can protect yourself like you and I did by getting vaccinated and boosted as needed and staying home when you're sick and celebrate the successes of the vaccine. Celebrate that. Now, as you just said, we have so many more tools to protect ourselves from COVID than we do for, um, metadenoma virus or para influenza virus, which every single year get many of my patients sick and in the hospital, because this is not a new concept that viruses tip people into crisis when they're particularly vulnerable.
[00:19:22] I mean, again, this is not new. We have done this before.
[00:19:26] MG: Well, I mean, I'll give you a good example of what you just said, what it reminded me of. Number one, my husband passed from cancer three months prior to the pandemic, and actually we didn't have hope fundamentally with bad cancer and we had moments of hope, but there wasn't. The thing about infectious disease is it's the other, unlike cancer, which is the self.
[00:19:48] I just wish, I kept in thinking as we were going through the beginning of COVID, I wish that I had someone to turn to during the worst parts of his cancer who would say vaccines work, therapeutics work. And so I wanted to be that person to help tell Americans that advanced therapeutics for an infectious disease, which is other. work. And it's not hopium. It's actually modern medicine technology. And then the second thing is it also could be that if you look at the world right now, I think there's a kind of a microcosm maybe on Twitter, but if you look at the world, I went to a large concert at something called the Chase Auditorium in San Francisco, which is like 20,000 people in an indoor space.
[00:20:30] And it was a large rock concert. And then later I went to Cirque du Soleil and. All these people, because I just was on the news a lot in San Francisco, came up to me at the concert and they said, Hey man, got vaccinated, rock on, you know, like, and they weren't, you know, distancing or masking. They were really living back with that joy that made life so meaningful.
[00:20:51] And I was really happy to see that is. It's kind of the point, right, of combating infectious diseases or combating anything that you're doing in medicine is the point is to infuse as much joy and normalcy into human beings lives as possible. And the other thing, and I really want to mention this, is my father was immunosuppressed during COVID. He was 88 and going through B cell lymphoma treatment. So this is as you know, when we talk about the vulnerable, this is really as vulnerable as we can get because he's not only vulnerable to a virus that is really age stratified in this risk. But he was on chemotherapy. And I kept on writing about how well the vaccines were working in my father.
[00:21:32] Trying to give people the personal anecdote. Because after vaccines and a booster, he had sky high antibodies during chemo. He sailed through his episode of COVID that he got at a family wedding, you know, very well. We did give him Paxilovid and I think that's very appropriate. I couldn't get at why... People didn't think the vaccines worked among the immunocompromised because the mRNA vacs, and I work with an immunocompromised population because I work with HIV, these mRNA [00:22:00] vaccines are so immunogenic. They're much more than like a whole virus vaccine or old protein based vaccine. So I'm really pushing the mRNA vaccines on my immunocompromised populations because they work so well.
[00:22:10] If someone wanted a Novavax, I was not encouraging immunocompromised, but Novavax was great for others. So it was just, again, like knowing that they really work. Even there was this idea that we would leave immunocompromised people out of the loop, but we weren't because we had this new technology that didn't leave them out and I kept on bringing my dad up to try to tell that I'm not just saying that even though I do work with an immunocompromised population.
[00:22:36] This is as bad as it gets and he's done very, he's done very well and he's back to normal life. He's, he went to the Shakespeare Festival in Utah the other day with his 92 year old friends. Yeah, he's 88, he's turning 89 soon.
[00:22:49] LM: It's amazing. I mean, you were always the champion of the T cells being cellular immunity, the arm of the immune system that protects against severe disease. So we learned pretty early on that it was post Delta that the vaccine could no longer block infection. That ship sailed, you could get 4, 5, 10 vaccine doses and still get infected,
[00:23:13] MG: Yes, exactly. T cells and B cells together are literally arming us from future protection from severe diseases. That's why it's so enduring.
[00:23:20:] LM: Right. And somehow that message just didn't get across, like the waning immunity conversation, it's like, I felt like, probably like you, I wanted to poke my eyeballs out because people thought waning immunity meant you were naked, like you're running outside of your house without any protection, when that just was never true.
[00:23:38] MG: These are basic principles of immunology that we learned in medical school. And I wrote a thread on Twitter just two days ago, cause I'd been thinking about it for a long time. How long does immunity last? Cause we've had some very nice new data about antibodies and it looks like it's going to last a long time for years actually.
[00:23:55] And so, and. The reason I thought about T cells so much is it's so hard to have seen an early AIDS and infection that HIV that hurt the very arm of the immune system, T cells that helped you combat infection. So I think about T cells all the time. I say the word T cells to my patients because what's your T cell count?
[00:24:14] But beyond the basic concepts of immunology, we've had a wealth of immunology information during the pandemic from really sophisticated groups in the UK and San Diego. They have done beautiful work that shows T cells cover all variants, and that's really important because I know we think we have to update the vaccine all the time, but they really do cover all variants because it's kind of a blanket of protection, and then B cells adapt their antibodies towards new variants.
[00:24:41] So there is really an adaptive immunity that we've shown both in this pandemic and from basic principles.
[00:24:47] LM: Monica, let's do a rapid fire Q and A. I'm going to ask you the questions that patients ask me every day About COVID and how to face the upcoming fall winter season. So there's a lot of buzz about these new variants, right? The BA
[00:25:03] MG: 286. Yeah. Yeah. I remember it because it's like 86, Ward 86. Yeah. Our
[00:25:09] LM: right. And the fear about this is that it has so many mutations that it may be, it may have escaped immunity from the vaccine. So when someone asks me, what should I do? Should I mask? Should I distance? Should I get another shot in the face of this new variant? What do I tell them?
[00:25:28] MG: So, there's two variants that keep on being talked about in the news, EG5 and BA286. And the one thing I will say is, actually, BA286 is not taking off like EG5 is. So we keep on saying, hey, there's a case in the UK, and there's a case over here. Actually, it seems extremely not very transmissible, and I think it's going to end up being one of those ones that go away.
[00:25:49] Because... If you're more transmissible, then you keep on rising in incidence. And the one that's rising in incidence is EG5. It looks like it's more transmissible than XBB1.5. These new variant directed vaccines that are coming out in mid-September are directed against XBB1.5, and they're going to very happily cover EG5 because there was just a paper on that. That EG5 and XBB 1.5 just differ by one mutation. So that's done with EG5. We'll know it's going to work.
[00:26:18] LM: But, let me ask you this. When you say cover, it doesn't mean you're going to, you can get the new booster and you won't get COVID. Right. So let's clarify that; it doesn’t block infection.
[00:26:27] MG: what's so important going back to BA286, which you were asking about originally, is that there's a concept of sterilizing immunity. What is sterilizing immunity? It's what we saw with smallpox infection or smallpox vaccine. And that was really the ability of Antibodies in the nose, which are called IGA to block all infections and the intramuscular vaccines that we get for COVID-19 do not produce that high of IGA in the nose.
[00:26:55] Guest: They did actually earlier on, or at [00:27:00] least the IGA was adequate to cover alpha. So there was blocking of transmission early on, but when Delta came along, 2 things happened. Number one, our antibodies go down with time and Delta had mutations across its spike protein and the vaccines didn't work as well against Delta, at least in terms of antibodies.
[00:27:16] But this is where our T and B cells are so important because there's never been a variant or a sub variant where the vaccines or your natural immunity don't work against at least in terms of cellular mediated immunity because T cell coverage is very broad so you can have lots and lots of mutations. But it still provides a blanket of protection and that's been shown again and again by Dr Setti's lab and other UCSD and then the second reason is B cells which T cells help produce more antibodies from those B cells are sitting dormant.
[00:27:50] Like you said they're in memory And then if they see another subvariant, even if it is BA286, they say, Oh, I, my job is to make more antibodies. I'm not going to make antibodies directed against some old variant in the past. That's not how these work. They're adaptive. I'm going to make antibodies directed against what I see.
[00:28:05] It will take a couple of days, but they will make, and you'll get infected, but you will be protected against severe disease. So there will be ongoing protection, even with both of these new variants with severe disease. If you've been naturally infected or had he vaccine before, and most people have had both, many people have had both. What about who needs boosters? That's the next question. I
[00:28:29] LM: Yeah. So as for boosters, so people are asking all about these boosters coming out at the end of September, early October, I remind people, cause most of my patients. I've had COVID and have been vaccinated. So they asked me, what's the optimal timing? I'm going to my daughter's wedding in November. What should I do?
[00:28:46] I remind them that again, you can get 10 shots and still get COVID. So they're not, these vaccines are not sterilizing. But if you wanted to try to time the vaccine to get a transient bump in your antibody levels before the wedding, which again, may not. It's like, if you jump into a freezing cold swimming pool and you're wearing a wet suit, aka vaccine, you're still going to get wet.
[00:29:11] MG: but it doesn't harm you with the severe disease. Yeah. Like it doesn't harm you.
[00:29:15] LM: Exactly. It's not, you're not going to have severe disease, but having had COVID and having had the vaccines previously is already going to likely protect you from serious outcomes. But if we're talking about the new booster, you might time it to get two weeks before the anticipated crowd you're going to be in.
[00:29:35] But, I mean, what do you think? Do you believe in like timing the vaccine to an event?
[00:29:37] MG: I don't actually believe them in timing them to an event because like you just said, I don't know if it's going to rise high enough to prevent infection at that event. What I actually really believe in and I wrote about this a lot of times is spacing the vaccines appropriately to get the best immune response.
[00:29:51] So I'll give you a good example that it looks like you should definitely wait at least four and likely six months since your last infection or last booster, whatever, they're the same thing. They're showing you the virus or parts of the virus in the case of to get another shot because you're essentially, you're going to interfere with that B cells trying to settle into memory, and this was data from the NIH.
[00:30:13] So, for example, my father, I would have encouraged him at 88 and going through chemotherapy to get the fall booster. However, he got, just got COVID, and it was in mid-July when he got COVID. So I'm going to ask him to please wait four months, regardless of events. So July, August, September, October, and then get the vaccine then. At least four months, maybe six so that he is doing exactly what vaccines are supposed to do, which is help refresh his immunity.
[00:30:41] Again, his immunity is more needing of refreshment than a young person's because young persons have very good immune responses to vaccines or infection.
[00:30:50] LM: It's a great point. And the other thing to remind people is that, you know, you can go to your daughter's wedding in November as planned. And if there's no one in the room with COVID, you know, it doesn't matter if you had the vaccine or the booster at all. In that moment, you can also be in any room anywhere because COVID is ubiquitous and it's not a wedding, but just because it's a wedding doesn't mean you're more likely to get it.
[00:31:08] That said, the virus tends to spread in closed Poorly ventilated spaces. It's just an odds ratio. It's not like weddings equal COVID and walking to the, the small boutique pharmacy, you're not going to get COVID. The virus isn't that smart. It's just different.
[00:31:24] MG: yeah, I think that's a really, not only is that a really good point, but the inoculum question, which I wrote about really early on. Oh, by the way, I was really mask focused very early on. In fact, when you say that I was on the, on the news, actually the first year and a half, it was all about masks, but I actually was talking about masks and this concept of inoculum.
[00:31:43] And there was just a recent paper that showed this is likely true, but it's amount, it's the amount of virus that you're exposed to. So that's why, yeah, dose. Right. And so, That's why in a closed indoor space, you'd be more likely if someone has COVID. Because the other important thing is not everyone has COVID all the time.
[00:31:59] That was the issue about treating people like they were vectors or something was wrong with them. Or we taught people to be scared of breathing. Actually, that is a thing that my patients said again and again to me. They said, I've been through one pandemic and I was told to stay. These are people living with HIV.
[00:32:15] And they said, I was told the way to stay. Stay away from people now. You're telling me to stay away from people and I can't even breathe like it was so hurtful the messaging a very soundbite messaging wear a mask save lives stay at home save lives Because it was not nuanced and spoke to the fact that It's really more likely when you have COVID that you're spreading disease.
[00:32:37] That was another interesting thing that changed with time is the degree of spread is really most when you're symptomatic and now we have really updated data around that But there was this idea that and I also wrote about that idea at the beginning but I changed my mind with time when I saw the data that you were spreading it when asymptomatic Just like most other infections. The majority of it is spread when you're symptomatic And that's good because that's what updating of data and recommendations means, right?
[00:33:01] LM: We have to have the epistemic humility to acknowledge that when we have new knowledge, we can change recommendations. That's not rooted in politics or ideology or, you know, who we vote for. It's, it's science change. It's iterative.
[00:33:14] MG: There was this idea that Americans needed simple messaging and I thought that was really insulting to the American public because I actually find Americans very pro science and very sophisticated. And I mean, just like everyone else. And so I didn't think they needed simple messaging, boosters for all mass for all. Like I thought they needed, you know, an explanation of the data instead of just say no.
[00:33:35] LM: Yeah. So there is sort of no more hot button. Issue than masking in this country, right? It became this sort of lightning rod and. It was just a fascinating sort of display of vitriol and science entangled with politics when masks are just masks. So when patients ask me now, should I mask in the fall?
[00:34:00] Should I wear a mask in an airplane? Should I mask when I'm outside? I tell people that despite searching for data to show that masks Reduce the risk for transmission. We failed to prove that they are that effective, particularly cloth masks and so even surgical masks. we do think is that a well fitted mask that is worn consistently and that is high grade can protect the wearer and whether or not to wear it is really up to you and your personal risk tolerance. Will I wear a mask when I'm sick with COVID? Well, I'll probably be at home in my room anyway, I wouldn't want to go to work sick or go to a social event sick. So first of all, I think there's no role for band aids because again, masks are for the wearer.
[00:35:00] But I also am trying to manage people's expectations because I think most people want to understand the reasoning. At the same time, there are some people who just want to be told. Mask up.
[00:35:10] MG: Yeah, I mean, so I will say that you're absolutely right, like I really go over the data on masks in this book. So it, because it was such a contentious issue, I really wanted to go over the data and it's kind of a vast section about all the studies, the Cochrane Review and negative studies in children. I mean, meaning negative harms in children, especially those who are learning how to speak.
[00:35:32] And so I really try to. comprehensively review that. And I agree with you that the only conclusion we can make as physicians and those who evaluate data is that if you all the time, we're a very well fit and filtered mask, like N95, KN95, KF94s, that you're going to protect yourself to a certain degree, but not always actually, cause it loosens, you'll take it off to drink something like it's not always, but that is all we can say. In medicine, putting all of this data together and I wrote the chapter actually for our infectious disease Bible on COVID and we really with another infectious disease doctor and we go over the data on masks. And that's what we conclude. You really mass mandates. It's not appropriate to put them back because of the different ways people are mass.
[00:36:16] And also because there is personal determination. If someone chooses to wear a mask or not, for example, my father. Again, I like to bring him up because he's high risk, except that I don't actually think he's that high risk because he's been vaccinated and now he's had COVID, but he doesn't hear very well because he had an accident 10 years ago.
[00:36:33] So masks are really, he doesn't like them because they interfere with his hearing. So it's when we think about people who are living with disability, um, it's a nuanced approach to what they would like to do. It has to be a personal decision, but I also reassure people so much about the vaccines that it's really interesting to see I don't think I have a single patient who's still masking. To my knowledge. They come in and they're like Hey, you convinced me. Like, you know, you got me to even take it sometimes if I didn't want to. And I, now I'm living with this risk like I've lived with other respiratory viruses.
[00:37:05] LM: At the same time, I, you wouldn't either shame anybody for wearing a mask if you want to wear a mask. That is your prerogative.
[00:37:13] MG: We are not very kind. Why don't, why are we so unkind? Like, we never, I don't know, in medicine the nice doctors are the ones who don't tell people how they have to be. I don't know, like, you just give them tools and then you let them...
[00:37:24] LM: Wasn't that the deal in medical school? I was, like, humility, empathy, compassion.
[00:37:30] MG: Not stigmatizing, not blaming, not people calling them idiots. So I can remember we treat lung cancer with compassion. If there's maybe an associate, you know, there is an associate of smoking. I mean, we'd never say, well, they don't deserve care. And in this epidemic, we were so unkind. We said the unvaccinated don't deserve care. Some people said…
[00:37:48] LM: Right. And we called children vectors of disease, grandma killers. I mean, you know, it's just not appropriate. It's not really in keeping with the sort oath of kindness that we take as doctors or
[00:38:00] MG: It really isn't in keeping with the principles of physicians.
[00:38:03] LM: it's also just not accurate. I mean, like, okay, let's talk about long COVID, which is real. I have a patient who has, I'm not satisfied with the diagnosis, by the way, like he carries a diagnosis of long COVID. But I look at the diagnosis of long COVID in this patient as a placeholder for when we actually get the diagnosis. I think COVID tripped a wire such that he has myriad. I mean, he has every organ systems on the fritz.
[00:38:30] He has profound dysautonomia. He has neuropathy. He has new anemia, renal insufficiency. I'm like a dog with a bone with my patients. We're going to figure out what's going on. He's going to have a bone marrow biopsy, a kidney biopsy. But my question is about long COVID. What is it? What is it not? And how did we get to a place where some of my patients and the general public are really afraid of it.
[00:38:57] MG: So I think that three and a half years and almost four years in, unfortunately we've done a disservice in terms of catching too many things into the long COVID diagnosis and not really being clean about our examination of data. So, What it looks like through all that noise and the WHO calls it an infodemic because you can put out papers that aren't very good and that's too much information and then you really look into it and you see that analyses were done improperly or it was observational confounded data or you didn't control for X or was ICD 10 not codes and it wasn't, you know, really understanding if they're inflammatory biomarkers.
[00:39:33] And if you put all the data together, it does look like any severe illness, sepsis. Influenza, COVID causes longer symptoms, but we knew that because as a specialist in infectious disease, I knew that from influenza. And that's why the incidence of this has gone down with the reduction of severe disease.
[00:39:52] So that's one good thing. That's good thing because we have the tools to prevent severe disease. Second is that we don't know all the contributors to. Why when you've had a severe infection that you get lingering symptoms, but in general, it has something to do with inflammation. We knew that for a long time in HIV and the anything that's even remotely promising or being tested as promising has anti-inflammatory properties, meaning like metformin looked promising in an observational study and it has anti-inflammatory. Property. So it's gonna go ahead and there's gonna be a study of randomized metformin, or a paxlovin study, like trying to kill the virus that actually closed early at Stanford. They are gonna study it more, but that would really imply that there was persistent R N A virus in multiple parts of the body.
[00:40:37] And we haven't seen that with other R N A viruses like hepatitis C, which is an RNA virus, does stay. But only with hepatocytes, only with liver cells. So we haven't seen that with other coronaviruses either and we do have six other coronaviruses. So that'll be studied but I'm more interested in the anti-inflammatory and I'm very interested, actually committed to preventing severe disease among, you know, the entire planet.
[00:41:01] And again, we have those tools to do that now with the vaccines and therapeutics. We need therapeutic access globally. We need something besides Paxlovid, which is Shinogi Protease inhibitors being studied. There's a Gilead nucleoside analog that's being studied. We're gonna have two more antivirals if they work.
[00:41:18] Hope they come soon because we need ongoing therapeutics and ongoing booster vaccination for people who are at persistent risk like older people and those on immunosuppressants in perpetuity for COVID because just like influenza, it will never go away.
[00:41:32] LM: Right. And we also need, as you talk about in your book, vaccine equity
[00:41:38] MG: Yes. It was so unfair.
[00:41:40] LM: The travel bans. I mean, as someone said early in the pandemic, that's like create it, trying to create a urine free zone in a swimming pool,
[00:41:47] MG: Oh no. Yuck. Yeah,
[00:41:50] LM: …until we vaccinate the world. First of all, that's just not, that's just not right. But secondly. Helping the collective [00:42:00] with immunity helps
[00:41:59] MG: It does. And that is, there's a long chapter on the book or like extensive on global equity and also how we should have learned more from HIV equity. And again, the same people who were urging HIV equity and of antiretrovirals weren't beating the drum. I thought for COVID vaccine and therapeutic equity, there was a lot of judgment being applied to human beings in this pandemic.
[00:42:19] I hope we get past this polarization, this politicization. I hope we increase trust in public health. We're going to have other problems in life and other pathogens, and we shouldn't be at this point.
[00:42:30] LM: I mean, if I were going to follow any guidance for the next pandemic, it would be your book.
[00:42:36] MG: It is a step by step, so I hope people do. The last chapter is a 10 point step by step.
[00:42:42] LM: It's a brilliant book. You're brilliant, Monica. And you kind of embody the humility and kindness that we hope other physicians and public health leaders adopt.
[00:42:51] MG: Thank you, but that's why I was drawn to you too, because I find you very compassionate, very kind and very loving with your patients. And that is the only duty of a doctor is to be kind, compassionate, meet them where they are and consider the entire patient. When I disappear into a room with a patient, it's just that patient and I, and that's, it is all about that person and it is holistic, every aspect of their life.
[00:43:16] LM: Monica, thank you so much for coming on the podcast and I hope to see you next time you're in
[00:43:21] MG: Thank you so much. I will.
[00:43:24] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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Manish Agrawal MD and Paul Thambi MD are oncologists who have spent decades caring for patients with cancer. They realized early in their careers that chemotherapy could treat the cancer—but what about the emotional, psychological and spiritual impact of facing mortality?
When they learned about the potential for medications like MDMA and psilocybin to help people gain access to parts of their minds they didn’t know existed—and to address the human experience of suffering—they quit their day jobs as practicing cancer doctors to found Sunstone Therapies, the sole psychedelic-assisted therapy research and treatment center in the Washington, D.C. area.
The data are increasingly clear: these non-addictive substances hold the power to expand consciousness and improve quality of life.
When guided by a trained therapist in the appropriate setting, even one experience with a psychedelic medication can help people unlock closed doors in their minds and to feel safe enough to explore its contents. They can be the catalyst for patients’ ability re-route well-worn pathways of negative and maladaptive thoughts, feelings and behaviors.
It turns out that science and spirituality aren’t mutually exclusive.
On this episode of Beyond the Prescription, Drs. McBride, Agrawal and Thambi discuss the inseparability of physical and mental health; the promise of psychedelic therapy to treat the psychological impact of cancer and other diseases such as PTSD, anxiety, and depression; and their shared excitement about the potential for these drugs to fundamentally expand the standard of care in medicine.
Bios:
Manish Agrawal, MD
Manish brings an extensive background and experience that spans medicine, engineering, philosophy, and ethics to his role as CEO of Sunstone Therapies. Driven by a deep interest in healing, Manish is particularly passionate about whole person healing and the transformative potential of psychedelic therapies. Manish previously held the position of Co-Director of Clinical Research at Maryland Oncology Hematology, where he dedicated 15 years to the care of cancer patients. He completed a fellowship at the National Cancer Institute, National Institutes of Health, and his residency at Georgetown University Medical Center.
Paul Thambi, MD
Paul brings deep experience in oncology care and clinical trial design to his role as Chief Medical Officer at Sunstone. He is a proponent of strong organizational culture and strives to create a compassionate, open and accepting workplace to advance whole person healing in medicine. As a medical oncologist, Paul developed important and meaningful relationships with patients, witnessessing their emotional and physical distress upon diagnosis and throughout treatment, leading him to explore psychedelic therapies to improve the emotional and mental health of patients fighting cancer. Paul completed his oncology fellowship at the National Cancer Institute and, prior to pursuing medicine, he began his professional career in engineering and consulting.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. Lucy McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight. We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond The Brescription.
[00:01:03] Buckle your seatbelt. Today we are going to talk about one of my favorite subjects, the re emerging field of psychedelic medicine. I truly believe it is going to change the landscape of modern mental health care in this country. I cannot wait to introduce you to my guests today, Dr. Manish Agarwal and Dr. Paul Thambi. They are oncologists who have spent decades caring for patients with cancer. They realized early in their careers that chemotherapy could treat the cancer, but what about the whole person? What about the emotional, psychological, and spiritual impact of facing a hard diagnosis and mortality? When they learned about the potential for psychedelic medicines like MDMA and psilocybin to address patients’ whole health, to offer some acceptance and insight and access to the patient's interiority in ways that they had never seen before, Paul and Manish left their day jobs as practicing cancer doctors to found Sunstone Therapies.
[00:02:13] This is where I am now sending some of my patients, not just to face cancer diagnoses, but also for anxiety, depression, and PTSD. Sunstone Therapies is the sole psychedelic assisted therapy research and treatment center in the Washington, D. C. area. The goal of Sunstone is to better treat the emotional and psychological impact of cancer and other disorders. Paul and Manish are contributing to the fundamental expansion of the standard of care in medicine and it is a wonderful thing to be part of and to watch. Paul and Manish, thank you so much for joining me today on the podcast.
[00:02:53] Dr. Paul Thambi: It's a pleasure to be here. Thanks for having us.
[00:02:55] Dr. Manish Agarwal: Yeah, it's great having you. Thank you.
[00:02:57] LM: The two of you together have backgrounds in medicine, engineering, philosophy, data science, and research, yet you landed in the field of psychedelics for a reason. Tell me why that is. What is so exciting about this field to you?
[00:03:15] MA: Paul and I both have been practicing oncologists for almost 20 years, and over time we got really good at taking care of cancer patients, their physical symptoms, but their quality of life was not always directly proportional to how they physically felt. And over time it really starts eating away at you, that you're not able to take care of the emotional health of cancer patients.
[00:03:35] When we saw this emerging field and started looking at the data, We visited and learned about it and then got training and explored to see is this real. And that's what sort of led us down this path is, for me personally I've always been into philosophy, that's why I have my masters in philosophy.
[00:03:54] I've been interested in the human side of medicine not just the science side. Both have fascinated me and this really brought both of them together. The reason that Paul and I both went into medicine is to treat people and to make them feel better. And really, for the cancer patient, for any patient, you have to take care of everything, not just the physical symptoms.
[00:04:14] PT: Everything that Manish said is echoed in my life and how I was drawn to this. And I think there were a few patients that really suffered emotionally that really hit home for me. And I carried that pain from what they went through with me. And when Manish showed me the data on psychedelic assistive therapy, it wasn't really the data, it was really more these YouTube videos where we saw how there were a couple of patients on the NYU trial and the Hopkins trial, and how they were before they went on that treatment and after. And there was a palpable change that you could feel through the video even, and it was just something that I wanted to be able to see if we can bring to our patients.
[00:05:00] LM: Can you give me an example of a patient who has been served by this treatment, maybe a cancer patient? I'd love to hear an anecdote.
[00:05:08] MA: There's a young patient with kids and a serious cancer, and had struggled with depression, didn't know anything about psychedelics, but really applied. And to see the change in his life, he's changed the relationship with his mother, who had a hard time with her son having cancer. And he was able to have a conversation with her afterwards, saying, I want my mom back.
[00:05:29] And then he was bleeding, when he went home for something else, he got a cut. And his young boy sat up and said, “Dad, are you dying?” And he was able to sit and have a conversation with him. He said, I would never be able to do those things before. And he was able to really sense into that. And then the other group that's really, I've sort of been really blown away by is the military that we've been treating recently.
[00:05:51] They have such complex things that they've seen, such complex trauma. And they've tried everything. I mean everything. For a military person to come and seek this care is not easy because the entire institution, it can affect their career if they talk about mental health. So they're desperate and to see the lives that are turned around, I literally wouldn't believe it if I didn't see it.
[00:06:15] And it's been powerful to see them going from, thinking about suicide regularly, to really no meaning, to a sense of despair, to not where everything is great and perfect, but they're having a fundamental change, and they want to live, and they want to reconnect, and they're building their lives back together.
[00:06:33] LM: I mean, that says everything that you need to know about why this is important. Acceptance, hope, peace, which isn't possible every day of the week, nor is it mutually exclusive with ongoing pain, as humans experience a myriad emotions on a day to day basis. But to think that there's something out there that could give people more agency and acceptance is pretty extraordinary given that we've had pretty poor tools to help people with emotional health and mental health. And so I guess my question to you is then, how do you see the psychedelics changing the way we think about mental health?
[00:07:19] PT: One of the things that can help to do is just to shine a light on this is a part of our health that we need to focus on. There is now these tools that are being talked about that can be helpful, perhaps more helpful than the existing tools and that allows people to start talking about their emotional health more to their doctors, to their family.
[00:07:44] And in terms of how these medicines can help, I think it's not just the medicine. I just want to talk a little bit more about that because the medicine does some things and would act on some of the same receptors that SSRIs act, but there's more to it than the medicine. You talked about it being an experience and it is that, and it's not always that it finds stories that are hidden, sometimes those stories are there and people feel them all the time, but they turn away from them. And what you need to do, what we're starting to learn with this is that you need to create an environment, a container as it's called in this space, that feels safe, that allows people to trust and be vulnerable in that space.
[00:08:32] So that when they experience those fears, and some of those stories may be hidden, some of them may be ones that they've lived with their whole lives, but now they can look at those. They can be with that story that they've felt, and face it. Because they feel a sense of trust, and they're with therapists or people who care about them.
[00:08:53] Who created a relationship with them that allow them to go deep into that story and find the pieces of that story that serve them and the, and the pieces of the story that don't and talk about that, integrate that into their lives, integrate that into their conversations with their families. It's that that does the healing more so than the medicine or as much as the medicine.
[00:09:17] LM: It's such an important point because I see patients Who I will kind of raise this idea to—people who have complex PTSD or who are facing terminal diagnosis. And sometimes they'll say to me, well, I tried mushrooms in college and [it] didn't do much then. And I just had a bad experience. I remind them that that set and setting matters so much.
[00:09:40] And I think it's such a good point that it's not just the medicine.It's the ability to feel vulnerable and safe, which is sort of this mystical aspect of the medications and then to face some things that you already did know you had and that weren't hidden. I think that's a great point.
[00:09:57] MA: Yeah, I mean, I think it's actually pretty nuanced in all of that, because one thing I tell people is, I think psychedelics allow you to access psychic material like no other thing that I know of. But they're not a magic bullet. And if MDMA cured PTSD, I tell people that anyone that goes to a rave wouldn't have PTSD anymore.
[00:10:22] But lots of people go to raves and still have PTSD. And so it must be more than the medicine. So it's not to take away from it, because I think you have access, but it is again, the context or, or how it's received. And so, it's like any medicine, the wrong dosage in the wrong context can be harmful or beneficial.
[00:10:37] And what you talked about, I think, is really nuanced, and I think it's important. We actually call it sometimes therapy assisted by psychedelics. Because a relationship allows you to really trust, and to trust yourself, and to go deep. And if you have that sense of trust, you're able to access material that you may not otherwise be able to.
[00:10:56] And a lot of times, sometimes injury or things occurred in a relationship and to have another wiring of your brain in a healthy relationship, to be witnessed when you were in pain or just to be held or to be supported is a different experience now than it might have been the time that it happened. And you're able to almost nurture that younger part of yourself.
[00:11:18] And so that's, it's really, it is quite cutting edge and that's one of the things that fascinated us because it's not… people want medicine therapy. It's like, it's really this combination of the two and, and so you can emphasize one, emphasize the other, but without the two and done in concert and the right setting, it just is not as effective.
[00:11:37] And so, you know, for us the therapists and the medicine are super important, but so is everything else. So the way the room is set up, the furniture, the music. The person that answers the phone, the way you're received, the way the follow up is. Because if you think about it, we all are sort of on alert, and you get a sense in your gut, can I trust this place? Can I trust this institution? Can I trust this store? We have relationships with people and institutions, and you start… some part of your psyche that's assessing for danger knows, how deep can I go? And so, you really have to build a place that tries to reassure even the unconscious part that it's okay to go deep here.
[00:12:18] LM: I think it's such a good point. And because I was going to ask you how much… let's take psilocybin, for example, which is the active ingredient in mushrooms, how much of that feeling of safety and trust is the chemical itself, and how much is the therapist, the experience of, you know, calling the front desk, scheduling, seeing the lighting, seeing the room, because I have patients who are in therapy for 30 years, even, who trust their therapist, who feel safe, they have a comfortable experience, but they aren't actually making the kind of progress that you sometimes see in patients who have three experiences with psychedelics in the right setting.
[00:13:08] MA: I don't think it's medicine that causes the trust. I think it's the environment. I think the medicine brings to the surface the issues that are there, and without the trust, you are not able to process them. And so, yeah, if they have a trusting relationship with their therapist, that's probably a really important piece, but then it's also deeper than that.
[00:13:29] Can the therapist handle whatever material comes up? Are they able to be with that? Do they know how to navigate that? And so, if there's distress or anxiety or fear, what they don't necessarily need is reassurance or minimizing of it, and it's how to navigate those waters that's a different skill set than traditional therapy. I don't think the medicine in itself causes trust, it just amplifies what's there, but in a therapeutic relationship trust can be built, and trust is an intrinsic part of each one of us, but it's to rediscover that.
[00:13:58] LM: Such a great point.
[00:14:00] PT: I echo all of that. I think also, what the medicine does is when you feel that trust, the medicine is a catalyst for you to go into those crevices that you talked about within the story. It may be a story that you know about, but now there's going to be chapters of that story that were hidden to you. And if you feel the trust, it allows you to do that in a way that I think is hard to do on your own. So there is that catalyst that you get from the medicine around that.
[00:14:30] LM: It's so gratifying to hear you talk about these sort of mystical and, and visible elements of the human experience because, again, I think that's what's missing in modern medicine, at least in the United States. We don't think about the 364 days a year you're not sitting with your doctor as health.
[00:14:52] We don't think about the way we feel in our bodies, the way we think, our self perception, the way we approach stress or vulnerabilities as health. When actually there are direct physical impacts of chronic stress on our bodies. There's direct physical impact of what you described as a vigilance.
[00:15:16] In fact, so many patients I see have been diagnosed with anxiety. And we'll use the word anxiety kind of casually, because it's so commonly used, people know the word, but, but actually when you dig deeper with a lot of these patients who have “anxiety” it's not necessarily that they worry excessively, or that they feel even anxious, they don't even often identify with that word, but that's the code in their charts: F41.9, but a more nuanced description of the way they feel, I think, is this vigilance, this sort of emotional, behavioral, and then sometimes medical reaction to feeling threatened that stems from an experience or set of experiences in their childhood. And we talk about adverse childhood experiences having physical and emotional mental health manifestations later in life.
[00:16:06] But I see patients all the time who have been diagnosed with anxiety, but whose symptoms stem directly from some adverse childhood set of experiences or experience. And then they have hypertension, binge eating, cardiovascular disorder, cardiovascular disease, racing thoughts, sort of like a twitchiness physically and emotionally when they are faced with stress. And I think that those are the people, as far as I understand it, who have had PTSD who are being studied first and foremost with psychedelics. Is that right?
[00:16:41] PT: Yeah, that's right. Right now, that's the indication that has shown the most benefit with MDMA.
[00:16:45] MA: Yeah, and to piggyback on, I mean, you've made a couple of points, I guess, and we should probably just touch on them. I think just working backwards… the last point, I think that if people do have these feelings of anxiety or depression, and I think when, um, a disservice we've done is pathologize them, that somehow that's the problem.
[00:17:05] And it actually is a sign of health because they're having a normal reaction to abnormal situations. And so, what trauma can sometimes be is that when you're very young you have a situation that was very difficult. But you responded normally, you would feel anxious or you'd feel depressed or sad. But then you didn't have support in that situation and so it got stuck.
[00:17:27] And then, now you react when things arise, your body, your psyche has a visceral memory of that, of that lack of safety or that issue that occurred. And so, it's not that the person is a problem, it's not a pathology. They had a normal response to an abnormal situation, whether it was an abusive family member or neglect or abandonment, whatever it was.
[00:17:50] It's just that, that situation isn't occurring now. And they need support to be able to work out of that. And what they do, what I've seen sometimes, is that actually becomes their superpower. So they get really sensitive. If you had power issues and somebody that powered over you wasn't, you get really sensitive to that.
[00:18:07] And you know in your body when something might be happening even before your mind does. And so, it's turning that story to say it's not a problem as much as how you can move on with it. And then the only other comment I was going to make is on the first part you were saying around, medicine, not looking at these other aspects of our emotional health and I think it's a historical time, really. I think for much of history, the shamans were the physicians and there was a connection between the mind, body, and spirit. And then to great progress, we developed a great scientific understanding of the body and develop antibiotics and other things that help us live a lot longer.
[00:18:47] And that's helped us, but then because your blood pressure is good and because your coronaries are clean and you don't have cancer, it doesn't mean you're happy. Now I think things are turning again, that the human is not just a biological entity, but it's also a spiritual, emotional, psychological… whatever you want to call it.
[00:19:06] And until you have all of that together. You're just not going to feel fully human. And so before there was this science versus religion or science versus woo woo or whatever it is. But I think more and more you'll see really respected neurobiology labs that are starting to, to talk about that. And you're doing MRIs of monks of brains and you're seeing that meditation causes certain changes.
[00:19:27] And then when we do MRIs of patients on psychedelics, going back to your point on vigilance, there is something called the default mode network. And that part of the brain is always looking for problems. It's the default mode. It's being vigilant. And that's the part that quiets down, other parts of the brain wake up, and they're able to start connecting.
[00:19:49] And so science now is backing up what's happening. And so there's not so much this tension there, and people are wanting to both be physically and emotionally whole.
[00:19:58] LM: It makes so much sense. I've heard Roland Griffiths talk about the experience that long term meditators can have as being the closest to the experience or benefits of psychedelic. Is that something you agree with?
[00:20:18] PT: Yeah, I think that, that makes sense. I mean, I think deep meditation allows you to see or feel things that you're feeling with a little bit of removal from that. And that allows you to have a different perspective. So, there is a correlation that can be made.
[00:20:36] LM: So, when people look at the New York Times and they see an article about psychedelic medicine, I think they automatically, in many cases, go to two thoughts. One, aren't these recreational drugs that are just for people in rock concerts in the 1960s? And two, that doesn't apply to me. This is for people who are really far gone. And so I'd love for you to speak to the sort of stigma around psychedelic medicine, where that comes from.
[00:21:08] PT: Yeah, and Michael Pollan talks a lot about this in, in his book How to Change Your Mind and how there was social and maybe political pressure around creating stigma. So I think that's some of what happened and then also you get into the 1980s where, you know, this is your brain on drugs, those commercials that would come out that really heightened my sensitivity as a child growing up in the 80s around that.
[00:21:34] And I think those are things that are hard to release. And now that we're starting to understand, and this is coming up again, psychedelics, realizing that these have been around for millennia. And they've been used by cultures as rites of passage for ways to solve the problems of a community. And I think now that those stories are coming back up and also the scientific data which provides people with a level of comfort, especially those people that have this fear of addiction and drugs and all of those things that I had when I was a kid, knowing that this is coming up in the medical institution. Along with the stories from the past are allowing for people to see this in a different way and to accept it more… I think one of the reasons that people feel safe doing this is that, especially like in the environments that we have at Sunstone, where it is in a sort of a medical environment, where our office, where we treat people, is on the campus of a hospital, and they can see the hospital out the window.
[00:22:36] And we're clinicians that have treated patients before as doctors, and it's in a research setting. That allows them to overcome that stigma, to feel safe as they embark on this thing they were told never to do in the past.
[00:22:51] LM: And so what do you make of this kind of... Emerging industry where people are taking the medicines off label with various healers and going on retreats in Costa Rica, because I worry, I don't know if you worry that if the set and setting are not appropriate, if the person who is supposed to be the guide isn't trained or perhaps worse, if the recipient of the therapeutic isn't aware of the potential risks and isn't guided in an appropriate way, then, then we might end up losing all the ground and getting these medications approved through the appropriate medical channels. Do you have that concern?
[00:23:32] MA: For sure, to some degree I do. I mean, I think there are probably great practitioners around some of those settings, but there's just no way to filter through that. And what I worry about, and I get more worried about, is the longer we're doing this, because we're treating complex PTSD patients, they're complicated. And things that come up, if you're not trained and equipped to do that well, it actually... it causes more harm. In fact, I was speaking with a senior psychedelic therapist who's worked for MAPS in Colorado, and she does only things legally, but she does a lot of integration work, and it's integration work for people that did psychedelics underground.
[00:24:17] And the biggest thing that she sees... As people got re-traumatized because they would have an experience and it was severe and the therapist wasn't able to be there. So then again, it felt like what I'm feeling is not okay, which is a feeling that they had the first time. And so she's having to rework through that.
[00:24:35] So in that way there's legitimate concern. And the other thing that I worry about is, we've seen this, that you talk to people, they seem fine, or you have one assessment of their mental condition, but it gets more complex and even they're not aware of it fully. And so you have to be really prepared for that.
[00:24:56] And the other point I was going to make is what you said, what you asked initially about the underground. But then you also said, people said, I'm not as sick, or how about that stigma? So I think there's a real stigma around mental health. There's a stigma around psychedelics and there's a stigma around mental health.
[00:25:13] And so this is both. What it still surprises me time and time again is that people just under report their symptoms, but they still seek it out. So there's sort of this dance. They're like kind of… I'm really kind of okay because it's how they dealt with it. It's like we don't have an environment where you're able to be sad or anxious and there's not something wrong with you and so people play it down and… this is totally anecdotal, but I swear it's worse with men. We'll see, they'll come in, and they're like, I'm fine, I'm fine, and then you, well I drink a lot, and then, yeah, I guess I have feelings of sadness, and then you do the scale, and it's like, wow.
[00:25:53] I think it's even harder for men to admit their emotional struggles and that's just a generality, but overall I think there's a collusion of denial around our emotional state and somehow you just have to be, present a certain way, and there's something wrong with you if you're struggling.
[00:26:07] LM: I mean, I have a couple of thoughts about that. One is thank you for saying out loud that men are more walled off than women to a woman. No, I'm kidding. I think you're generalizing, but yes, let's just acknowledge that we are very self aware species, women, that is. Secondly, I think we all have a level of denial.
[00:26:22] I think denial serves us sometimes, right. Denial is a way of partitioning off pain so that we can cope and function. But then when denial takes on a life of its own and the stuff that is in the denial closet is sort of seeping through the edges and like running out of the bottom of the closet and informing our health, that's when denial is no longer serving us. It's when it's actually in the driver's seat. So it strikes me that the experience, in an appropriate setting with a psychedelic, could help people pull that wall down or open that closet and, and take a look inside and maybe rethink how they approach that thing they didn't think they could approach.
[00:27:08] And then secondly, yeah, mental health still has a bad rap when, as you both know, we all have mental health. It's not a feature you can kind of opt out of as like the human without the mental health. And as you said earlier as well, we tend to medicalize and pathologize mental health.
[00:27:30] So in a way that's good because we are acknowledging that these have medical consequences, that an anxiety disorder is a medical condition, as opposed to just a personality flaw, which was what some people think of it as. But we also tend to label and sort and diagnose conditions that are just normal.
[00:27:50] Like, of course, when someone has been raised by an alcoholic parent and they have been conditioned to sort of be a certain way, sort of invisible or good or not a problem, that is going to have an impact on their health such that when they get into a therapist's office or a doctor's office in their forties and their maybe that's not depression.
[00:28:13] Maybe you had a response to an experience and sure the symptoms are that of depression, but it's actually something more complex, more nuanced. And so I'm not really asking you a question. I'm just making an observation that we're up against a lot as we market these medicines and therapeutics to people because of the stigma around mental health because of the stigma around drugs But I think if it's done well—which is why Sunstone and other research institutions exist—if it's done well, and we can actually help people understand that their interior lives their past their stories have relevance to their health. And that yes, having clean coronary arteries and nice blood pressure is great, but it's not sufficient for health, then it really, I do think is going to change the way we think about health.
[00:29:04] It’s already changed it for me. It's just that it's not legal yet in DC. And I haven't tried psychedelic medicine. I want to, it has changed the way I think about emotional health. I mean, I've been thinking about mental health and health in this way, my whole career, but I don't think modern medicine has given doctors really permission to do that.
[00:29:20] And so I wonder what you think is in the pipeline. Are these things going to be FDA approved in the next five years, ten years? Are people going to be able to access these therapeutics? Are there going to be enough guides to appropriately shepherd people through the process? What are we looking at in the next year or five years.
[00:29:41] MA: I just want to comment a little bit on what you said around the denial piece. I think that denial actually is quite healthy. And on where your neurological system was, when you experienced something, it might've been, it probably was overwhelming and the proper and healthy response would have been denial and to put it into a box.
[00:30:00] It's just that now it's not necessary and it's not integrating back into your life. And so I'm very wary of pathologizing any of these things because they're usually healthy. It's just in the context now. And so I just make that one point and the other one around the mental health issue that, it's good that we're talking about it, but I think that we wouldn't want a life without emotions, right?
[00:30:23] If you push down your anxiety and your fear, you also push down your joy and happiness and love, the things that we humans live for. And so they sort of go both hand in hand and you can't have both of those.
[00:30:38] LM: Yeah, sort of like when we talk about alcohol when we're sort of self medicating, right? It blunts distress, but also blunts joy, libido, life. So you can't selectively numb. You also can't selectively be the human without an emotional life because that wouldn't be good. Then we'd all be like chat GPT or AI, right?
[00:31:00] PT: Yeah, yeah, and it just, I'm just going to piggyback on that denial part of things too, because I think one of the things that's important to remember is that people have built up these ways of denial, of sort of pushing things away. Psychedelics, like we mentioned before, can be a catalyst to break through that denial.
[00:31:17] That can be, you can lose your balance when that happens. So I just want to highlight again how important it is to have that integration and that container afterwards because you can't feel that way afterwards. You have to be with people that help you find that centeredness again.
[00:31:35] And in terms of access and what's happening, we talked about how MDMA has been studied in PTSD for some time now. And there are two phase three trials. They're showing significantly positive results. And that might be the first medication that gets approved as a psychedelic for PTSD outside of esketamine, which has been approved for depression. And that might happen in the next year or two and we will hope for that.
[00:32:01] And psilocybin is behind that in terms of how it's being used in various types of depression, and more and more information is coming out around that looks good, and perhaps if it continues to look good, that could be the next medication that gets approved. We'll see. So I think those are the things that are happening in terms of access and how we get this to people if they are approved, if they do show that they are effective, You're right, I don't think our healthcare system is built for this right now and there aren't enough therapists that are trained in this to treat everyone that has PTSD or even a half the people that have PTSD that might qualify for MDMA or for psilocybin in some sort of depression. And that's what we're thinking a lot about.
[00:32:48] We have investigated how to do this in a group setting, with group preparation, taking the medicine as a group, and having integration as a group. We find it is not only a way that introduces efficiencies, but we also see therapeutic healing with that approach, too. To be able to be connected with another group of people that have something similar to what you have or what you're going through, whether that be cancer or PTSD or depression, and to develop this bond during the sessions that you have with each other around preparation and integration, we think that's probably going to be therapeutic, too.
[00:33:29] That model also allows for more people to be trained on this. So, we're trying to think about how to do that from a group setting. We're trying to think about how digital tools can be used to improve or to give us efficiencies in this setting, but also remembering that there's compassion that's needed with this, so not to overuse digital processes. We're thinking about that as well. How do you do scheduling and other things? So, I think there's a number of problems to be solved around access, but they're solvable.
[00:34:00] LM: And so if you're listening to this and you're thinking to yourself, wow, I've been in therapy for 10 years. I'm on Prozac, but I still feel anxious. I'm sure there's some parts of me I haven't really discovered. This sounds really interesting. Or if you're just listening and want to try psychedelics, where would you go?
[00:34:18] Would you have to enroll in a clinical trial? Would you call Sunstone? Would you wait until MDMA is approved? What would you do if you were curious and wanted to participate in the research or the therapeutic elements here?
[00:34:31] MA: I think the first thing you would do is look for a clinical trial. And so, there are many, many places now that are doing research throughout the country and internationally. And certainly at Sunstone, we have five studies open now, and we will have another three more open this year. We have them in depression and anxiety and PTSD and cancer and family members of cancer patients and so there's other places that have that. So I think that's sort of the most rigorous way to get that. And I do think that some medicines, as Paul said, will be approved next year. I think that, I cannot underemphasize the importance of the context and the safety. What you don't want is to do something and get worse and so you want to make sure that you have safety if you're not good on that road.
[00:35:16] And I think we've talked a lot about the upsides of psychedelics and we're talking about that because so much of mental health right now, we don't have great treatments for, but we're still really in early days and we still have a lot to learn. Who's most going to benefit? Which people are completely contraindicated for?
[00:35:36] How do you get people ready? And so I understand the hype because people are desperate. And at the same time, I want to be cautious in that I think we're still learning about how to use these powerful medicines.
[00:35:50] LM: Yeah, I mean, I think one thing I am concerned about in particular, and I know this is out there in the public, is the potential risk for someone, particularly in their 20s who may be predisposed to schizophrenia. Is there a link between the use of psychedelic drugs and either the awakening or the schizophrenia or mental illness?
[00:36:09] Plus, as you've already talked about, this idea of not having the right set and setting not having the appropriately trained guide or the feeling on the patient side of of safety and trust such that people get worse. So what are the absolute contraindications right now in your mind?
[00:36:28] PT: Some of them are around people who have a tendency towards manic episodes. Like bipolar disorder with mania because that has been described where people had manic episodes after having a psychedelic experience, so I think that's one firm contraindication right now, at least in research trials.
[00:36:49] The others are—there are some cardiac effects that people worry about with some of the psychedelic medicines, so if there's a history of abnormal heart rhythms or a potential tendency to have an abnormal heart rhythm, that's another contraindication. Some of them like MDMA have sympathomimetic effects, which means they can cause the heart rate to go up and the blood pressure to go up. So if someone doesn't have controlled high blood pressure, or if they have underlying heart disease, they may need to get evaluated with a stress test and things like that to show that things would be safe if those conditions happen.
[00:37:27] LM: And what about, so many Americans are on SSRIs, so is there a contraindication? For people who are on SSRIs or who are on any other medications at all?
[00:37:38] MA: In terms of the SSRIs, right now we taper people off of them, and it's less about safety as much as efficacy, that we think it might blunt the depth of the response of a psychedelic. Although there are ongoing studies that are bringing some of that into question, and so they probably do work maybe at a higher dose, and so it's not an absolute contraindication, it's certainly not a contraindication for safety, it's just a, you might limit its efficacy.
[00:38:02] LM: Interesting.
[00:38:03] MA: And some of the drugs that can prolong the QTC, there's some concern around that, and so we certainly do EKGs on all the patients.
[00:38:11] LM: What is so great about the way you're describing the research is that you have a healthy level of respect for these medications. You have enthusiasm, but it is tempered with appropriate caution. So thank you guys for joining me. It's been so fun learning about Sunstone. I've been grateful to you guys for taking some of my patients into your clinical trials, and I can't wait to see what's next.
[00:38:37] PT: Thanks for having us, Lucy.
[00:38:39] MA: Yeah, it's just been great getting to know you.
[00:39:03] LM: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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Kelly Casperson, MD, is a urologist, sexual medicine expert, and best-selling author. She is on a mission to empower women to live their best love lives.
In her wildly popular book, You Are Not Broken, Dr. Casperson breaks down the common narratives that women have been told about their bodies such as “I shouldn't enjoy sex,” “I can't get any better at sex,” and “It is my partner's job to give me pleasure,” in order to help women play, explore, and normalize their sex lives.
Combining the power of mind, body and relationships, she breaks down the societal barriers that keep women from fully embracing their sexuality and intimate experiences.
On this episode of Beyond the Prescription, Dr. McBride and Dr. Casperson discuss desire mismatch, relationship communication, and tools to help put women back in charge of their health and sex life.
It is time to normalize healthy, enjoyable sex worth desiring, and Dr. Casperson is here to help!
Submit your question about sex (or anything else) for this Friday’s Q&A right here!
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
The transcript of the show is here!
[00:00:00] Dr. McBride: Hello and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my Dr. Caspersons like I do my patients, pulling the curtain back on what it means to be healthy and redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their stories and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond the Prescription. Today on the podcast I have the honor of speaking with my friend who's also a doctor, a urologist, and a sexpert: Dr. Kelly Casperson. Last year, Kelly published the wildly popular book You Are Not Broken: Stop shoulding all over your sex life. It's a combination of real stories, conversation starters, and journaling prompts about how to have a better sex life. Kelly and I agree that mental health is health, that sexual health is health, and that women and men are unstoppable when we're armed with tools, facts, and the agency to be healthier from the inside out. Kelly, I'm thrilled to have you on the podcast today. Thank you so much for joining me.
[00:01:53] Dr. Casperson: Thanks for having me.
[00:01:54] Dr. McBride: So let's get right after it. You are someone like me who believes that health includes many of the invisible components of our everyday life, including sexual health, mental health, a sense of agency over our everyday thoughts, feelings, and behaviors. You're someone who was trained in urology, which is a surgical field. And when people think about urologists, they typically think about male doctors treating male genitalia.
[00:02:27] Dr. Casperson: That's right.
[00:02:27] Dr. McBride: So, talk to me about what it's like to be a urologist in a male dominated field that people consider as a male dominated field, and then tell me how you came to understand Sexual health as a sort of a moral imperative to dispense more information about.
[00:02:44] Dr. Casperson: Well, currently practicing urologists in America, 9% are female. We’re getting there. We're about 30% of the residency slots. There's only like 200 residency slots a year. So it's not like we're going to change the 9% much quickly. It's been great. I kind of… It was challenging to get into urology.
[00:03:01] I loved that. I loved the instant gratification of urology. And people are still surprised, you know, that there's women in urology and it's like I've been out of residency for 10 years now. So I don't know if that's gonna change in my career at this point. It's not changing fast. But the superpower that being a urologist brings to this whole sex medicine discussion is that I treat men.
[00:03:22] And so I get to see every single day how men are treated, and I see how women are treated, and it just becomes so glaringly obvious that we treat these two people very differently, and I get to have a voice because of that. In contrast to the gynecologists who don't see that we don't downplay men's complaints, and we don't say, well, that's just a quality of life issue, or yeah, you're just getting old.
[00:03:42] We don't treat men the same way we're treating women. And the sex meds and… I met a patient who was crying in my office, and the more I opened my eyes to what was going on, the more I said, I thought, “this is a huge problem, an absolute huge problem,” which I hadn't really seen before because I was not taking care of women's sexual health before I kind of got awakened to it. It's going to be lifelong work because we've got a lot of work to do.
[00:04:11] Dr. McBride: Let's, so let's talk about that for a second. I think what I'm hearing you say is what I experience myself as a doctor and as a person is that we countenance men's sexual dysfunction with ease and there's a whole specialty built around men's sexual health. It's urology. But in reality, urology encompasses everyone's pelvic floor, everyone's sexual health.
[00:04:37] It's just that men tend to go into the surgical field, men tend to treat men, and then the narrative is that it's really for men. So, it sounds like that was your professional path, and then you began noticing, like I do, that, hey, guess what? Women have sexual health as well. Women have pain with intercourse, low libido, pelvic floor dysfunction, vaginal dryness. And like men, women are entitled to pleasure, the absence of pain, and most importantly, in my mind, is access to nuanced information about their own bodies.
[00:05:13] Dr. Casperson: Yeah, we do a very interesting thing… to stereotype what we do, we say all of men's problems are biological and all of women's problems are psychological. And so like, you know, he's got erections issues. That's a blood flow viagra problem. We've totally forgotten it could be anxiety, depression, all that stuff going on.
[00:05:30] And conversely with a woman, we're like, oh, she's just depressed. She’s just too uptight. We're like, no, she can have a hormone problem. Women are allowed to have biological issues also. And we really put them in these little containers and then forget about the humanness of everybody.
[00:05:47] Dr. McBride: Yeah, I think, you know, we can walk and chew gum at the same time. We can have anxiety about performance, and that can be rooted in an experience that was traumatic. It can also just be rooted in low self esteem, or... Body image issues. You can also have low libido from not having enough estrogen because you're going through menopause.
[00:06:08] In other words, human beings are the complex sum of different parts. So to assume that women have sexual dysfunction because it's all “in their heads” and to assume that men have sexual dysfunction because it's all just a blood flow problem is to reduce people to these very simple parts and then assign them by gender. And that is not our job as doctors. It's also just completely inappropriate. It's really depriving people of the deep understanding of how their body and minds work in tandem.
[00:06:40] Dr. Casperson: That's right. Absolutely.
[00:06:42] Dr. McBride: Okay, so you are sitting there with a patient who's crying. Who's and by the way, I tell my patients when they cry in my office, like, you know, they're sort of apologizing or “oh, sorry. I'm just emotional.” And I'm like, oh my gosh. I mean, it’s not that I want you to cry. It’s a sign that we're getting somewhere that we have something to talk about. Let's peel back the curtain on what that is. It doesn't always mean you're depressed, it doesn't mean you're a hot mess. It just means there's something that's going on that we need to connect to your body.
[00:07:10] So what are you finding women come to you to complain about vis a vis sexual health, sexual dysfunction? What are the main issues they present to you with?
[00:07:19] Dr. Casperson: The two main ones in my office would be vaginal dryness/general urinary syndrome/menopause. Right. So low estrogen in the pelvis causing pain with sex, burning, tearing, low lubrication, decreased arousal. It's kind of this umbrella cause. And then the second one is I don't really want to have sex, or a.k.a low libido. Oftentimes, that one's so fascinating, because it's often times not a low libido problem. They don't know what it is. They come in and they say, “I have low desire,” and you talk to them and you're like, that's not what's going on at all. And a lot of times with sex, they think it's about sex, but it's just a couple's communication problem.
[00:07:56] You’re assuming what he's thinking, he's not talking to you about what he's thinking, you think this is a sex problem. You're like, no, no, no, this is just a relationship communication problem. But like sex gets involved and like, it just all goes haywire.
[00:08:09] Dr. McBride: Yeah, I think you're right. I think sex can be the final common pathway for a lot of personal and then relationship challenges. I was talking to one of my patients who is actually a family lawyer, like she helps people get divorced or helps people not get divorced. And she, not surprisingly, said the three things that people commonly fight about or have troubles with in their relationships are kids, money, and sex.
[00:08:33] Those are three very vulnerable touch points in our lives. And so I think you're right, that sex can be kind of a symptom of other issues. But in and of itself, it's important. It's part of how we connect with our partners. It's how we experience pleasure. It's a part of the human experience. So to deny someone a conversation about what it is, whether it's truly like a body parts malfunctioning problem or it's an emotional challenge is really not okay.
[00:09:02] And your book, We Are Not Broken, speaks to this notion. That having trouble with sex, whether it's desire or the parts not working isn't a personal failure or a commentary on your ability to perform as a human. It's—the diagnosis here is human. It's common. I've, I mean, patients come into me all the time, I'd say of all ages, but often in their middle age and they'll sheepishly say to me, “I'm really embarrassed to say this, but I just don't want to have sex. I love my partner, but I'm just not interested.” And they act like they're the only person who's ever thought that before. And I'll say, “Oh my gosh, I could feel in an auditorium full of women who feel the same way.”
[00:09:47] They feel ashamed. They feel guilty. It's not a lack of love for their spouse. Sometimes it is, or their partner. It's simply that they are struggling to connect the body and mind and they need some support and they need to be given permission to have that conversation.
[00:10:04] Dr. Casperson: Yeah. Or they've just been having crappy sex their whole life.
[00:10:06] Dr. McBride: Well, that's also true.
[00:10:08] Dr. Casperson: And I don't want to downplay… there is now an actual medical condition called hypoactive sexual desire disorder because they have to DSM this stuff to get FDA approved for meds, like the entire thing that medicine is, but a lot of this “low libido,” I never believe them anymore because it's there's oftentimes something else and so I'm like, “well, what about sex? Is sex good? Do you like it?” And either the answer is “yes, I love it.” And then I say, “well, you don't have a problem. Stop worrying about low libido. Just go prioritize that amazing sex you're having.”
[00:10:38] It's not normal to have a spontaneous desire in a long term relationship. And number two, if they're like, yeah, I could take it or leave it. I'm like, well, that's how dopamine works. You're never going to desire something you could take or leave, right? Like anchovies on my pizza. I'm whatever, right? Like I don't desire it.
[00:10:54] And then it's just like, go have the sex worth desiring, which is very stuck in depth. That's easier said than done for a lot of people. They've spent how many years having the exact same unsatisfying sex because they're having sex the other person's desiring. And really prioritizing desire equality and pleasure equality within a relationship. It's like, you don't actually have a low libido problem. You have a sexist man problem.
[00:11:18] Dr. McBride: interesting. So to break that down a little bit, and I'm assuming you're talking more about women, are sort of subjugating their needs and not allowing themselves to experience pleasure as much as men are. And therefore they are just having bad sex, which of course they don't desire because why would you desire something that's not that great.
[00:11:38] Dr. Casperson: I'm stereotyping, you know, a heterosexual relationship here. Within any partnered relationship, you're going to have somebody who wants sex more than the other person. That's just, that's desire mismatch, and it's completely normal. And we need to normalize that. Like you, you want to, you know, drink seltzer water way more than I do.
[00:11:54] Why is there so much seltzer water in our house? Between two people, there's always different things going on. So just normalizing desire mismatch, normalizing it. The other thing to normalize is it's not the lower desire person's job to come up to the higher desire person's level. It's to work within the relationship, to be like, what does our relationship need sex wise to keep everybody happy?
[00:12:14] You can fulfill some of your needs outside of my vagina, right? Now, I can say that very easily because I've been talking about sex for years, and you have to be a little more nuanced in a relationship where you've maybe never talked about sex before. Because couples don't talk about sex, and then there's a problem with it.
[00:12:31] Well, I don't have the basics of how to talk about sex when it was good. Now it's broken and I really don't know how to talk about it. So even just communication skills about sex is important. But yeah, I think a lot of women and there's we do not have much research on this…We've got decent studies in like college students, which are not long term committed relationships of “well, that's what he wanted. He wanted to do it. I did it to keep him happy.” Kind of this like mercy sex to control another person's behavior. I don't want him to get grumpy. I don't want him to get mad. And so you're having sex for that reason instead of connection and pleasure. And then you come in thinking you're the problem for having low libido. It's not a low libido problem.
[00:13:13] Dr. McBride: Well, and there's nothing like shame or guilt to crush a libido that's already low, right? If your relationship with your partner is rooted in shoulds, then…
[00:13:24] Dr. Casperson: You need to have sex with me more is the least sexy thing you can say to somebody. The partner is telling the low desire person that they're broken and they need to up their game. Like it's worked zero out of one million times to approach it that way.
[00:13:38] Dr. McBride: Well, it's also, it's probably less than zero of a million times in the sense that the telling someone how to feel and then promoting the sort of shame narrative is like the ultimate libido crusher.
[00:13:50] Dr. Casperson: Yep. I'm inadequate and I'm supposed to love this thing that I don't love more.
[00:13:54] Dr. McBride: So I think you're right, Kelly. I think at the end of the day, it's about communication. It's about shared responsibility for meeting each other's needs. And I think that's hard in the modern era. I mean, who has time to sit down and have a nuanced conversation about sex? But I think we have to.
[00:14:11] Dr. Casperson: Right. And even I, I live, I work in a very traditional medical 15 minute visit, right? And now through my years of work, I have the podcast and the book because I cannot explain this to anybody in a 10 minute visit and undo the years of socialization that women are passive and women's pleasure doesn't matter as much.
[00:14:30] Male orgasm is what we prioritize—penis and vagina sex for heterosexual people. That's the only sex you should be having. All of this stuff. And they come in with low libido, and then somebody's gonna slap them on a drug. And not undo all this biopsychosocial stuff. I saw a woman literally yesterday. She had a painful vulva and vagina from menopause. Painful to the touch, like even her just touching herself hurt. Somebody threw her on testosterone for low desire. And she's like, “well, what do you think about the testosterone?” And I'm like, “I'm a urologist. I love testosterone. I'm very comfortable with testosterone.”
[00:15:06] But putting somebody on testosterone who has a painful vulva, who's never going to want to be touched in the first place, you're completely missing the boat on this. We have to address the pain before we can address the desire. And so it is complex, which is why I love this topic. And I get to keep talking about it for years.
[00:15:22] Dr. McBride: Yeah, I think it's treating people from the inside out, right? It's like not band-aiding them with prescriptions and referrals and drugs before we understand the patient. We are not just a set of organs. We are thinking, feeling people who absorb the public narratives, who have been raised perhaps in our own families to think about pleasure and desire and sex itself in a certain way. I think deconstructing those narratives in our own lives, and then being comfortable talking about those things is key. And I think having people like you, Kelly, out there talking about these things in a very matter of fact way is gradually changing the narrative and hopefully empowering women to ask the right questions and give themselves permission to feel.
[00:16:09] So it's interesting because you and I both know that doctors are hurried, doctors are rushed. No one has time anymore with their doctor, unfortunately. You've got the field of gynecology, which is tasked with doing your pap test, writing your mammogram order, you know, checking your pelvic exam, and how can they possibly fit into a 10 minute or even 5 minute visit a conversation about pleasure, desire, feelings, behaviors, your relationship. It's just a tall order for a single specialty, right?
[00:16:45] Dr. Casperson: they can't. I mean, the other thing that we completely forget in this narrative is that women are 50% of the population, that we've completely ignored in this arena, talking about both menopause and sexual health. 50% of the population, there's not enough gynecologists. Even if they could spend 15 minutes, there's not enough of them.
[00:17:02] This is primary care, internal medicine, psychiatry. We really all have to get on board, because, like, we're not a minority recessive gene problem. This is 50% of the world.
[00:17:16] Dr. McBride: Right? Yeah, so one of the things I try to help patients navigate is the medical system, given that we have needs the medical system cannot meet. Arm people with the questions to bring to their gynecologists. Instead of being a passive recipient of like the pap test and the referral to the mammogram, make sure you're bringing your needs to them and asking for their advice and then making a separate appointment just for a conversation if needed because it's not the doctor's fault necessarily that they don't have time to talk about sexual desire.
[00:17:49] Patients are conditioned not to ask about it. Doctors don't have time. It takes a whole lot more time to counsel someone on the nuances of behavioral health and pelvic floor and the nuances of hormone replacement therapy, which we'll talk about in a minute, than it does to hand someone a referral for a mammogram and say, you look great, see you next year.
[00:18:07] Dr. Casperson: Totally. And that's where good resources like your podcast, my podcast, the book is like what you read it, you can consume it. And then our podcast will give you better resources. So you come in with the current menopause guidelines. You come in saying, “I've already talked to my partner about this.”
[00:18:22] Dr. Casperson: You're telling us what you've already done. You're an engaged person. We actually want to help, right? And so it's like setting that person up to be successful in the doctor's office and to ask why so many, like, you know, the hormone thing. So many women will come to me and they'll be like, well, they took me off my hormones.
[00:18:38] And I'm like, “why?” Why is a very natural question for me, right? And they're like, oh, I don't know. I didn't ask. So it's very okay to just ask why in a non threatening way to your doctor. Like that's my other doctor pro tip and how to talk to…
[00:18:51] Dr. McBride: Ask why.
[00:18:52] Dr. Casperson: Ask why so you understand!
[00:18:53] Dr. McBride: This is your body. This is your life. So let's talk about hormone… it used to be called hormone replacement therapy, HRT, now it's called menopause hormone therapy, MHT. Whatever the acronym, what I want to talk about, the conversation every woman should be entitled to about hormones and using hormone replacement therapy to offset the symptoms of menopause and to prevent the myriad potential downstream effects of the absence of hormones.
[00:19:25] Just to frame the question and to give listeners a little bit of a sense of what I'm talking about, what is menopause? Menopause is defined as the absence of a menstrual period for a full year. The average age in the U.S. of menopause is 51 and a half years. That stretch of time of not having a menstrual cycle can occur in the mid 40s, it can occur in the mid 50s, there's a range.
[00:19:46] And during the lead up to menopause, people can experience a variety of symptoms. As a result of our ovaries no longer making robust amounts of estrogen, progesterone, and some testosterone. That can be hot flashes, night sweats, vaginal dryness, urinary tract infections. Pelvic floor, pain with intercourse, mood instability, rage, although maybe the rage is just that we're pissed off, but yes, rage.
[00:20:15] And then, of course, there are the less immediate and the long term effects of not having estrogen and progesterone in our bodies, which can be downstream osteoporosis, accelerated cognitive decline, cardiovascular disease, risk of heart attack and stroke, and then the accumulated... downsides of having painful sex or having urinary tract infections.
[00:20:41] How many women do I see in their 80s, for example, who end up having recurrent urinary tract infections? They're not even sexually active, necessarily. And that could have been ameliorated with hormone therapy from the get go, when they went through menopause at age 50, for example. So, the question I want to ask you is rooted in the reality that since June 2002, when the Women's Health Initiative study was halted prematurely and the headlines read, “hormone replacement therapy is bad for you.” We really took a hard right turn in the public square on the narratives around hormones. People, patients, doctors included, have been loath to prescribe estrogen and progesterone for menopausal symptoms.
[00:21:30] Because the narrative that came out of that 2002 press release was that we're doing harm to women. And that wasn't the narrative before 2002. In fact, hormone replacement therapy was almost standard of care. So you probably read the same article I did, the Susan Dominus article in the New York Times.
[00:21:51] I cheered. I also was sort of pissed off reading it, thinking where has the New York Times been for 20 years, but we'll take it better late than never. Her article was a very beautiful explanation of why we deprive women of conversations around hormone replacement therapy. It's easier to not talk about hormone replacement therapy because it's a long conversation in the doctor's office.
[00:22:18] There are risks of hormone replacement therapy, potential risks, but there are potential risks of not being on hormone replacement therapy. And you and I both know, and even the expert society for menopause has said that if given within the first 10 years of a woman's last menstrual cycle, hormone replacement therapy in most women does more good than harm.
[00:22:47] In other words, protecting you from long term downsides of not having estrogen, osteoporosis, heart disease, stroke, etc., and treating the menopause related symptoms that you have right now, arguably is better for most women than it is to not be on hormones. Now, of course, there's nuance. If you have a personal history of estrogen sensitive breast cancer, that's going to be a different conversation.
[00:23:15] To deprive women of that conversation and the choice, given that risk is everywhere and there's risks of hormones and there are risks of not being on hormones, that is where we need to start. Empowering women with facts and rooting their decisions. In their risk tolerance, not ours.
[00:23:32] Dr. Casperson: Yeah, I mean, I'm to the point now in my journey of like you want to control women? I got a good idea. Make them afraid. Now you have complete control out of them.
[00:23:41] Dr. McBride: Oh my gosh, Kelly, amen, hallelujah. And I'm not a conspiracy theorist, but sometimes I think I am.
[00:23:46] Dr. Casperson: Well, you start, I mean, you just do this long enough and you're like, I see what's going on because you know what you do when you empower women and you take their fear away, you give them agency and you give them the ability to choose what they want to do with their body—you give them a hell of a lot more power. So, that’s my whole thing now—I'm here to get rid of fear.
[00:24:04] Dr. McBride: It's very simple. If you have fear and shame in the driver's seat…
[00:24:07] Dr. Casperson: Boom. Control.
[00:24:08] Dr. McBride: We are castrated, literally. If you have fearlessness and facts in the driver's seat and a good guide, like a Kelly Casperson or some other doctor who knows the data and is focused on you, not risk aversion for their own protection, liability wise, reputation.
[00:24:29] I don't know what doctors are doing when they're depriving women of the conversation or gatekeeping on hormone replacement therapy. But when you put women in charge of their own health and give them tools and information, watch out world.
[00:24:42] Dr. Casperson: Yeah. Totally. I mean, the other thing, the other piece I think that Western medicine's very bad at is preventative health care.
[00:24:49] Dr. McBride: A hundred percent
[00:24:49] Dr. Casperson: And if we look at menopause hormone therapy as preventative health care because what we're doing is we're preventing heart disease We're preventing dementia. We're preventing osteoporosis. We're preventing genital urinary syndrome of menopause. We're preventing diabetes. And you can't see that—you can't measure that especially on an individual scale. And so you're like well just come in when you've got osteoporosis and diabetes and heart disease. We know how to treat you; we've got tons of meds for those problems. But to change the paradigm and be like, I would like to actually not need to be treated for those things, so I want to choose hormones. Hormones aren't perfect, but they will certainly help prevent to a decent amount.
[00:25:27] Dr. McBride: Right, I mean people get strokes, people get heart attacks, people get dementia for other reasons, age related, genetics, environment. But certainly the data are clear that again starting hormone replacement therapy within the 10 years of the last period tends to decrease those risks. I think what you're touching on, Kelly, is a really important point that Western medicine does a very poor job—arguably abysmal job—at countenancing things we cannot see, we cannot measure.
[00:25:56] So, we can measure cholesterol, we can measure your pap test, we can look at your mammogram result. We can hold it in our hands and look at the number on the computer screen. It is less easy—it takes more time, it takes more conversation and it takes an appreciation of the invisible components of the human condition—to weave in the invisible components of life.
[00:26:20] If you live to your 105 and you have perfect cholesterol and no stroke and you're, that's great. But if you are suffering for 50 years from pelvic pain, the absence of a healthy sex life, depression, anxiety, that's not necessarily a good thing we've done for this person. We can help them live long, but what about living well?
[00:26:43] And by the way, they're not mutually exclusive, right? It's not like I'm saying, oh, let's knock 10 years off your life to give you a good sex life. I'm saying, let's give you both. Let's be greedy. Let's give you quantity of life and quality.
[00:26:53] Dr. Casperson: I think the other thing is menopause is 30 years of your life. Right? Like, maybe you aren't going to decide to go on hormones this year, but go learn some more. You can start them next year, if you want to. Who do you want to be? What do you want your health to be? What do you want to be doing when you're 70?
[00:27:12] And think about your future self, and think about how I can set her up. Because once you're 70, once you're 75, you can't start on hormones. The risk is… because, I mean, you can. Technically, you can. But the risk goes up if you don't start during what they call the healthy cell hypothesis. You’ve got to start on healthy cells, keep them healthy, not start hormones on unhealthy cells. So we're going to think, and I asked these 50 year old women, I'm like, what do you want to be doing when you're 72? What's your plan? And a lot of them see moms with dementia, moms with osteoporosis, they've got stiff joints, they can't get on off the ground with the grandkids.
[00:27:49] And you don't have to be that. You can choose, as best as you can, to set yourself up for great health. But it requires making decisions in your 40s, in your 50s, to eat right, sleep well, exercise, possibly use hormones. We don't think about our future selves, and then, you know, she might be kind of miserable.
[00:28:08] Dr. McBride: It's true. You know, you probably get this question, and I do too, from middle aged women. How can I age gracefully? What can I do to preserve my cognitive, mental, physical health over time? And that's a great question and oftentimes patients have gone on the internet and they've bought some supplements, they've bought some gizmos, they've bought some gadgets.
[00:28:26] They've bought into, unfortunately, the sort of worshiping at the false idols of wellness. Not that I'm anti wellness. Wellness is part of our job, right? It's just that let's be real about what is evidence based and what is woo woo in a nice package. As you can tell, I have an opinion about that.
[00:28:43] Dr. Casperson: A woman sent me on Instagram today, what do you think about this supplement? And I'm like, are you drinking alcohol? Stop. Are you exercising? Start. Are you working on love in your life and keeping your brain expanded? So many people, they get narrow in their brain and their flexibility to think as they get older.
[00:29:03] Dr. McBride: Well, I think that we think that, not that people are not smart, but I think we start to think that agency exists in a pill. That we'll have control if we can just take the right supplement or pay enough money for some guru, right? And it's not that I know everything. I certainly don't. You can ask my children. It's that there is no vitamin, supplement, or pill for quality of life. It's an integrated sum of different components, and that includes agency. And hormone replacement therapy, arguably, is one of the things we can do to help people “age gracefully.” There's a whole industry, as you know, about treating the symptoms of menopause by nibbling around the edges of the symptoms, like giving you a little eye of newt and a tincture of whatever to treat the various symptoms.
[00:29:50] And people will go, women will go to extreme lengths and extreme costs to avoid being on hormones because of the narrative. And so the industry is now promoting, look, you can do non hormonal treatment. And that's fine. I'm not saying, I don't think you are either, that every person should be on hormone therapy.
[00:30:09] Not at all. It's not appropriate for everyone. It's not even necessary for everyone. It's just that we should be honest about the data and not steer people down the path of the sort of pseudoscientific wellness industry at the expense of their actual mental and physical health.
[00:30:24] Dr. Casperson: Our good friend Rachel Rubin is quoted in that New York Times article: “menopause has the worst PR campaign in the history” of health problems which is just brilliant.
[00:30:32] Dr. McBride: What is it about Rachel? She has these sound bites. That was such a freaking brilliant quote. I'm just cheering for her so big, like you are.
[00:30:39] Dr. Casperson: mic drops, but it's true. Like we just, we think it's a hot flash and then we think it's done. I literally saw this woman this week. She's 52. She's having heart palpitations. She's having weight gain. She's having a moodiness. Her hot flashes are so debilitating. She has to pull over her car because it's unsafe to drive during her hot flashes.
[00:30:56] She went to her provider. They're like, we'll run some tests, see what your hormones are. She's 52, hasn't had a period in two years.
[00:31:03] Dr. McBride: smells like a duck, sounds like a duck, looks like a duck.
[00:31:05] Dr. Casperson: To me, I'm like, you're in raging menopause, you need no blood work. Get this woman on some hormones. Like, it's so obvious to the people, because menopause and hormones actually isn't that hard. We just didn't get educated. It's not hard. We just didn't get educated for two decades. We've had two decades of doctors who didn't get taught how to treat menopause because of the Women's Health Initiative.
[00:31:27] Dr. McBride: Right. And so people who are listening are going to think I'm making this up to make a point, but I'm really not. I spoke to a gynecologist this week who is someone I've worked with for decades. And again, like I'm not in the business of like demonizing other doctors. In fact, I am only as strong as my community of doctors I work with, but my patient is experiencing menopausal symptoms that are hard to measure.
[00:31:49] Depression, some heart palpitations, anxiety, sleeplessness, and just feeling like she's a broken person when it's all menopause. So I call the gynecologist because I want to be a team player and ask the gynecologist, what do you think about putting her on fem ring and progesterone? This is a low risk person.
[00:32:08] And she's a year and a half out of her last menstrual cycle, this was her response. She said, “can't you just put her on Prozac for the depression?” And I said, well, I'm not sure she's actually depressed. I think she's just experiencing menopause. And I think that the Prozac would maybe help with mood, but it's not giving her the treatment that is going to actually help, in my opinion.
[00:32:34] She said, “can't you give her gabapentin for night sweats?” I said, absolutely. We can do the workarounds. But what are you worried about, if I may ask, about putting her on true hormone replacement therapy? Basically, the hair of the dog that bit you. And the answer was, “well, the FDA has really only approved hormone replacement therapy for vaginal dryness.”
[00:32:55] I said, “well…”
[00:32:56] Dr. Casperson: Not true.
[00:32:57] Dr. McBride: Look, I believe in our federal government. I'm a registered Democrat, but the FDA does not know my patient. The FDA, as far as I'm concerned, is a gatekeeping apparatus to deprive women of these medications. So, as her doctors, you and me, I feel obligated to offer her something that would actually help with her symptoms instead of nibbling around the edges. What do you think? And she agreed with me. But it took a long conversation. She agreed.
[00:33:24] Dr. Casperson: Well, it's the… hormones are this, it's this myth that they're so dangerous. It's like Zoloft has a black box warning for suicide. Is that the preferred drug? Besides the fact that it isn't treating the root cause, which is low hormones.
[00:33:36] Dr. McBride: Exactly! The level of scrutiny on hormone replacement therapy is beyond any degree of scrutiny I've ever seen for any medication, right? Urgent cares are prescribing Z packs for viral colds. I mean... What are we doing by not giving people a natural hormone if they need it, if they want it, and they know the potential downsides?
[00:33:57] Dr. Casperson: 100%. Like, once you, like, as you see, you see this. It's absolutely insane. If there was a drug that helped men live three years longer on average, every man would be on it. That drug is called menopause hormone therapy. Multiple studies showing decreased immortality, increased longevity, and not only living longer, but living quality of life longer.
[00:34:22] And I'm like, do you, do you think the man would be on that if he had a chance to be on that? Heck yeah. And it's like, there's no other drug. What other drug is going to give you three extra years of life? None of our drugs, to my knowledge, have that kind of longevity data.
[00:34:37] Dr. McBride: That's right.
[00:34:37] Dr. Casperson: Estrogen has that longevity data. We blow it off. We would not blow it off if that was given to men.
[00:34:43] Dr. McBride: So tell me what your advice to people listening to your audience, Kelly, is, when they are experiencing symptoms of menopause, their doctor may not be... interested, have the time or be informed with all the data to have a discussion. What do you tell patients to do? In the power dynamic in a doctor's office, patients assume that their doctor knows everything.
[00:35:06] They're making a good judgment when frankly we are experts and we do know a lot, but it is not our job to tell you what to think, tell you how to feel or to gatekeep on medications. It's really to arm you with the tools you need to manage your everyday health. So what do you tell people? In your audience as a good kind of like three or four rules of thumb to bring to your doctor when you're experiencing menopausal symptoms or want to just have the conversation.
[00:35:35] Dr. Casperson: Yeah, I would bring in the 2022 North American Menopause Guidelines. That's a great document. Doctors are going to respect that document. And it really downplays a lot of fears. It says how safe it is. So come in prepared with something that the doctor, they speak that language,
[00:35:50] Dr. McBride: Great. And I'm going to link to that document in the show notes.
[00:35:53] Dr. Casperson: Yep. And the other pro tip for talking to a doctor about something that they might not be comfortable with is to say, you know what I'd like?
[00:35:58] I would like just to try this for a couple of months and then I'll come back and I'll report back and if it didn't go well, I'll stop. Does that sound okay to you? Most doctors are going to say yes to that. Because now they've got a plan, they know you're not going to follow up, right? I'm like, I just want to try this and see if it works.
[00:36:17] Dr. Casperson: Because I think people get so bent out on hormones, they're like, “should I do hormones? Should I not? Should I? Should I not?” It's like, “just try them. You could stop. This is not an amputation. It’s all okay.” But having that sort of plan with your doctor, I truly believe in a long term doctor patient relationship. They're going to know you. That is the best case scenario. That doesn't always exist in our current culture. And when women don't get what they need, the smart ones are going to go online. And that's where these online clinics for menopause are coming from, because they see we are underserving women.
[00:36:51] Doctors do not have time. This is a nuanced conversation. And I think for better, for better or for worse, but I think for better, you can get your hormones online now, because you don't have to spend two hours on hold trying to make an appointment with somebody you might not even know anyways. The healthcare system is kind of bad.
[00:37:08] We're not set up for this, right? We're not set up for the New York Times changing, like, how many millions of women are like, maybe I can consider hormones now. We're not set up for that. We're already full, right? So, I think that's the role of where these online clinics are going to come from. I think some are doing it well.
[00:37:26] Certainly, I don't think it's as good as an inpatient, in your town doctor patient relationship. But we do not have capacity to start tackling these issues like we should. And so I think that's the new role for the online clinics.
[00:37:39] Dr. McBride: Yeah, I think you're right. I mean, it's sort of like the sort of outcrop of mental health providers who are doing virtual care to kind of meet the demand. I don't think online virtual therapy is ever going to replace in person therapy, but it's better than nothing. And if they're doing good and people have managed expectations about what an online therapist can do, Great. Similarly, a lot of these outposts, these online businesses helping people with menopause and hormone replacement therapy are really doing good work, like MyAlloy, which was founded by a friend of mine, Ann Fullenweider. Their medical advisor has been Sharon Malone, who's a really well respected OBGYN in DC.
[00:38:20] She's a friend of mine as well. And they're doing really good work trying to empower women with facts and information because not every woman, A, has a primary care doctor, B, is comfortable talking about these things with that doctor, and C, has the time and the visit to even discuss these things. So I think it's a net.
[00:38:38] I just think people need to be careful about the snake oil salesmen that are telling you to just take this little eye of newton—whatever the metaphor is—because we run the risk of misinformation running rampant as it already is.
[00:38:52] Dr. Casperson: Well, yeah. And people's dollars are limited and you go online and it's this supplement, that supplement, what's the new trendy thing? And at the end of the day, I want you to save your money. Like, you really don't need a lot of that crap. And hormones are pretty darn cheap. They've been around since the 60s and 70s, right?
[00:39:08] If we came out today with a drug that made you live three years longer, you know how much that would cost? Right, and you can get that in estrogen for pretty darn cheap. So that's…
[00:39:17] Dr. McBride: The other point I'd love to make that people don't always understand is there's a lot of brand sort of marketing lingo around hormones that in my opinion is unnecessary and make people think that there's like a right way or a wrong way to take hormones. The word bioidentical is sort of having a moment and I would just say to people you don't need to buy fancy brand name hormones.
[00:39:41] CVS, Walgreens, not that I'm a big believer in chain pharmacies, but your regular pharmacy has “bioidentical hormones.” In other words, micronized progesterone, which is the safer progesterone and estrogen in the form of a tablet, a patch, a ring is as close as it can get to not being actually your tissue.
[00:40:03] So, I think that people need to be educated on the fact that it doesn't have to be fancy, formal, or brand name, and to be suspicious of anybody who says that they have the best bioidenticals and someone else doesn't, because that is just made up.
[00:40:20] Dr. Casperson: It's made up. Well, I mean bioidentical came because we were so freaking afraid of hormones That it was a way to help people stop being so afraid of hormones. So it was kind of like this lead in to safety But I tell people it's like you know when you like you have a granola bar and it says natural on it and I'm like, you know what the natural means like legally And they're like, no. And I'm like, it means nothing. It doesn't…
[00:40:43] Dr. McBride: It's a marketing word. It's a marketing word. It's a way to deescalate fear and to make people feel like it's their own body. When... if we can just get rid of the charade and just get people what they need, we'd be a lot better off.
[00:40:55] Dr. Casperson: Yeah. And most cheap FDA approved products are “bioidentical.” They're the same.
[00:41:00] Dr. McBride: It is funny. I mean we're all victims of sort of messaging and narratives and we're beneficiaries of it too. But it's just you have to know what the landscape is because otherwise we get tripped up and believe things that are just sort of hoo ha. I'm a victim of that too. And do I buy soap at CVS that says lavender scented calming soap?
[00:41:24] I was laughing at that the other day and I was like, as if this soap is going to calm my noisy brain down. If it did, that'd be awesome, but I'm just going to manage my expectations that this soap is just going to clean my hands.
[00:41:37] Dr. Casperson: Yeah. A hundred percent. The power of the mind, man. I mean, going back to sex, placebo gives you an erection 40% of the time. So, the mind is very powerful.
[00:41:45] Dr. McBride: It's true. So Kelly, as we come to the close of our conversation, I'd love to just thank you for helping change the narrative for arming people with facts and tools and for reaching people where they are, because this is where we need to be in the modern era. We need women to have truth, access to tools and to take shame and fear out of the driver's seat.
[00:42:12] Thank you so much for joining me.
[00:42:13] Dr. Casperson: Thanks for having me.
[00:42:15] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected]. The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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Dr. Mary Claire Haver is a board certified OBGYN and women’s health advocate who has helped thousands of women going through menopause actualize their health and wellness goals. Dr. Haver’s goal is to empower and educate women in their mid-lives, and help women advocate for themselves in the doctor’s office.
On this episode of Beyond the Prescription, Dr. McBride and Dr. Haver break down the myths and facts about menopause and hormone therapy. They discuss the harms of fear-based narratives in medicine and the importance of balancing risk to help women live longer and healthier lives.
So, should you or shouldn’t you take hormone replacement therapy? Dr. McBride wrote a longer piece about this decision-making process here.
The upshot?
* Menopause is defined as having gone a full calendar year without a menstrual period. A woman’s midlife decline in estrogen and progesterone levels can cause short-term symptoms (like hot flashes, vaginal dryness, and insomnia) and can increase the risk for long-term health problems (like cardiovascular disease and osteoporosis).
* In general, menopausal hormone therapy (MHT) is considered safe for most healthy women when it is initiated within 10 years of menopause.
* Estrogen itself does not seem to increase the risk of breast cancer for the vast majority of women.
* Unless she has had a hysterectomy, a woman should take estrogen and progesterone together.
* Micronized (aka “bioidentical”) progesterone does not increase the risk of breast cancer; synthetic progesterone does seem to increase the risk, but only slightly.
* Dr. McBride recommends not panicking about the new Danish study suggesting an increased risk of dementia in women who take MHT. Why? It was an observational study (not a randomized controlled trial or RCT) therefore it cannot prove causation; the study population used oral estrogen and synthetic progesterone which are not the standard of care in the U.S.; myriad RCTs show the opposite finding: that MHT is likely protective against premature cognitive decline, especially when started early.
* Too many women needlessly suffer through menopause because of false narratives about the safety of MHT and because discussions about quality of life often aren’t prioritized.
* Don’t take it from her! Dr. McBride encourages you to share the latest expert statement from the North American Menopause Society with your own doctor to help guide your decision-making process.
* Women are entitled to make their own decision about hormones, armed with the data, and with an understanding of their unique risks and benefits.
Dr. McBride will answer your questions about menopause and HRT on Friday. Submit your question right here!
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
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The transcript of the show is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor, I've realized that patients are more than their cholesterol and their weight.
[00:00:31] We are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my free weekly newsletter at lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts.
[00:00:57] So let's get into it and go Beyond The Prescription. Today on the podcast, I'm talking with the incredible Dr. Mary Claire Haver. She's a board certified OBGYN who has helped thousands of women who are going through perimenopause, menopause, and beyond actualize their health and wellness goals. She realized after decades of practice that she hadn't learned as much as she should have about the science of menopause, aging and inflammation.
[00:01:27] She really took a deep dive into the science and has created an online course called The Galveston Diet with the goal of empowering and educating women in their mid lives. Mary Claire, thank you so much for joining me today on the podcast.
[00:01:41] Dr. Haver: Thanks for having me.
[00:01:42] Dr. McBride: Let's talk about the fact that women have been notoriously excluded from medical studies. Women have also been deprived in many ways of access to nuanced information about their own bodies and health. And so it's interesting right now that menopause is having this moment, right?
[00:02:01] It's like Susan Dominus wrote this beautiful article about how women have been misled, and I think women around the country, around the world were like, “yes. Oh my gosh. Thank you for seeing me and hearing me.” And I think it's a historic moment where women are finally recognizing that they need to be seen and heard, and that their menopausal symptoms are not just in their head and that it's time to get the facts to put ourselves in the driver's seat. So let's just start with that article. So tell me what happened when that article in the New York Times came out, did that change increase the volume of phone calls coming to you? What? What did it mean to you?
[00:02:39] Dr. Haver: I think it just validated and reinforced what I was already doing on social media and that really people were sending me the article by the thousands—I was getting tagged. I was getting, “why aren't you in this article?” I didn't even know it was being written, and I just felt like it was really well done and it really was the tip of the iceberg, but it was the first meaningful publication—in such a respected area—that really was drawing attention to the problem. But women have been screaming about this for years, and I'll tell you, so I finished my OBGYN training in 2002, which was also the year the WHI stopped the study on hormone replacement therapy and basically ended any meaningful research into menopause care for at least 20 years.
[00:03:36] And when I graduated from that training program, I would've sworn on a stack of Bibles based on my board scores and my level of training that I was a world-class menopause doctor. And it wasn't until 20 years of clinical practice that I realized in going through my own menopause journey that I was not a good menopause doctor, that there were serious gaps in my own education and training.
[00:04:03] So when you look at an OBGYN residency, and I know this because I was a former residency program director, and over half of what we do, probably 55 to 60% of what we do is obstetrics. All important stuff. Then everything else gets shoved in the box called gynecology. And in that gynecology box we have pediatric gynecology, we have GYN oncology, we have reproductive endocrinology, which is fertility.
[00:04:29] We have everything, and menopause gets a tiny sliver of that time and education. There are only 20% of residents coming out today who feel that they had any clinical menopause training, meaning went to a clinic where they were specifically addressing a woman in menopause. When multiple surveys have been done, the doctors are realizing this is important, but they didn't get the training.
[00:04:56] Nothing was really focused on that. Not to say that what we learned wasn't important. It's just menopause has never been prioritized.
[00:05:03] Dr. McBride: Why do you think that is?
[00:05:05] Dr. Haver: So I think it's a perfect storm of societal norms of medical education, how women have been treated through the years in medicine. I don't know about you, but we had a saying, if it walks like a duck, it talks like a duck… we love a differential diagnosis.
[00:05:22] We love a standard set of symptoms, and I think one of the problems is that menopause has a very diverse presentation in each woman. Even identical twins can have completely different symptomatology. We're all going through something very similarly endocrinologically as far as our ovaries beginning to lose their eggs, and the decrease of estrogen and leading to the full menopause with no estradiol. But how that presents in our bodies is very different. So unless you've been trained in the nuances of how to pick this up, then you're going to miss it unless she's just waving a flag with hot flashes and no periods. But the symptoms of menopause begin in perimenopause seven to 10 years before.
[00:06:03] So we have this entire generation of women who are suffering and going to their healthcare providers with this kind of laundry list of symptoms. And if the doctor isn't trained to realize that this constellation could all have a common denominator of decreasing estrogen levels, they may get told it's all in their head, or this is a normal part of aging, or there's nothing we can do, white knuckle it, suffer through it, you'll be fine.
[00:06:30] And we're just leaving them without… they're walking out feeling dismissed, feeling like maybe they're crazy and that they are going home to cry over, I can't get any help for this.
[00:06:42] Dr. McBride: I couldn't agree with you more that medical school and residency, while of course I learned a ton, did not do a fantastic job at countenancing suffering that you can't see, that you can't measure in a blood test or a CAT scan, night sweats, hot flashes, vaginal dryness. Pain with intercourse, relationships, struggles because of sexual dysfunction, decreased arousal—what we call low libido.
[00:07:10] Those are things you can't see. Plus, women are used to suffering. We are very comfortable in the space of suffering, right? We deliver babies. We have our nipples cracking and bleeding with these infants hanging off of our chest. And I think it's not hyperbole to say that women are pretty good at suffering.
[00:07:34] And so I think it makes sense that gynecologists who only have so much time in the office to talk to patients. And who only had a certain education and that didn't encompass menopause per se. And when we aren't comfortable talking about things we cannot see and we can't measure, we can't quantify despair, that it gets brushed under the rug.
[00:07:57] It reminds me a lot of, my interest is in the relationship between mental and physical health. The relevance of mental and physical health, how we all have anxieties, we all have fears, we all have moods, we all have relationships, and we didn't talk about that at all in medical school. My psychiatry rotation was about addressing patients who are in institutions and paranoid schizophrenics, which of course is relevant, but it's not speaking to the universality of mental health as a common sort of ground zero for our whole health. So I think what you and I are doing is trying to shine a light on these universal phenomena—grief, loss, anxiety, moods, relationships. And in the case of women, the fact that every single woman, if you live long enough, will go through menopause as defined by…
[00:08:47] Dr. Haver: A hundred percent.
[00:08:48] Dr. McBride: The gradual decrease in the production of estrogen and progesterone, and a little testosterone, and we need to talk about it. We need to be open about it. We need to empower women with the questions to ask their doctors.
[00:09:03] Dr. Haver: I think the other thing to mention here, and it's really getting brought to the forefront with the political discourse going on right now, is that society in general stops valuing a woman somehow after she's done with the ability to reproduce. And we're seeing it, and I think this is manifesting in how we are not focusing on menopause care, why the research dollars are not going to menopause care.
[00:09:30] When you look at women's health spending at the NIH, it's, I think it was several billion, but only 45 million was spent on anything to do with menopause, and that was like 0.3% of the funding in women's health was going to anything to do with menopause when a third of us living, breathing, functioning women are suffering right now due to their menopause journey. We're just not valuing them.
[00:09:58] Dr. McBride: And then we have, of course, the headlines that came out in 2002 when the Women's Health Initiative was stopped early, and the headlines screamed things like, I mean… you put the word breast cancer out there in a headline and the fear of breast cancer. What happened in 2002 is that this enormous study, that was the first study on hormone replacement therapy powered by NIH and Bernadette Healy was the first female head of the NIH was stopped early because there was a signal suggesting that hormone replacement therapy causes breast cancer. Now, when you hear that as a woman and women are—we're smart, we're paying attention, we also are not immune to fear-based messaging. And so talk about what happened and how it has taken us so long to correct the narrative on hormone replacement therapy as a treatment for menopausal symptoms.
[00:10:52] Dr. Haver: So the fanfare with which that announcement was made was pretty much unprecedented in medicine. There was a press conference called in DC and there were reporters everywhere, and one of the—it was only one person in the study who decided to release this information. This was before the study had actually even been published.
[00:11:17] Healthcare providers couldn't even read the article and decide for themselves. So everyone's in their offices, I'm in residency, and we're just doing our normal day-to-day lives. And it was like a shot went off across the world in our world that estrogen causes breast cancer, hormone therapy is going to kill you.
[00:11:36] And that was the take home message. And all of us were reeling. We're reading the headlines. No one can get their hands on the study for another week or two. 80% of prescriptions for hormone replacement therapy stopped immediately based on one announcement. And in the 20 years, that 22 years now that have ensued since that publication, so much of that has been walked back on multiple levels.
[00:12:04] It's been reanalyzed, looked at, retracted. People have apologized who were in the study, and none of that has gotten any of the fanfare. It's been really hard. The best book that came out was Estrogen Matters, the Avrum Blooming book. He really broke that study apart so a layman could read it and understand, and the fallacies of the study and the things that it really represented.
[00:12:28] So the average age in the study was 65 years old. We weren't talking about newly menopausal women in the beginning of their menopause journey and the potential benefits, the estrogen only arm had a 30% decrease risk of developing breast cancer. No one talks about that. And that women who were diagnosed with breast cancer, it was itI believe the risk went from 3.2 to 3.8% if I have the numbers correct, and that represented a 25% increase, but it was still very small. And that the women who were on hormone replacement therapy at the time of their diagnosis had a 20 to 30% higher survival rate, five-year survival rate than the women that weren't.
[00:13:09] So women were not allowed to digest that information and decide for themselves what their tolerance to this risk was, and if they still, for the health benefits, for their quality of life, they were absolutely denied. So in desperation, I think practitioners began giving people antidepressants, which can be helpful, but it's never the gold standard and the gold standard for menopausal symptoms is always going to be estrogen. But doctors just were so terrified. The patients were terrified. They didn't want to get sued.I remember being fearful of being sued for giving hormone replacement therapy.
[00:13:49] And the mantra, like I was taught, kind of was only give it if she's threatening suicide, like if there's no other option, you know, otherwise do anything other than giving her back the hormones she so desperately needs.
[00:14:02] Dr. McBride: Yeah, it's such an example of the paternalism of medicine or maternalism because I think women doctors too were depriving women of these hormones, but it's more this sort of like sense that doctors should be the gatekeepers and we should be the arbiters of the patient's risk tolerance. It reminds me a heck of a whole lot of COVID when instead of giving the public sort of nuanced information about, you know, calibrating your risk mitigation measures to your actual level of risk, given your age and underlying health conditions and number of vaccines.
[00:14:39] Instead just telling people, here's what you do. Regardless, we are going to tell you how much risk to tolerate in medicine, as you well know, first of all, patients don't trust doctors who think they know everything. I mean, I don't, and I certainly don't know everything. And I think we owe patients…We owe women the ability to make their own decisions based on the facts and the information they have, and we need to countenance the invisible suffering, just like we countenance the risk of breast cancer. Certainly there are risks of hormone replacement therapy and there are risks of not being on hormone replacement therapy. And let's talk about both and let's try to thread that needle with the understanding that life is risky.
[00:15:21] There's risk everywhere you go. You could live your life not on hormone replacement therapy cuz of the fear of breast cancer that may be completely founded because of a family history, a genetic predisposition, but then you're going to have to tolerate perhaps an increased risk for cardiovascular disease, an increased risk for premature cognitive decline, an increased risk for osteoporosis, sexual side effects, etc.
[00:15:42] We owe women the discussion, the conversation. But as you know, the conversation takes time. And then it takes more time when you have to undo a fixed narrative that a woman is bringing to the doctor's office saying, “oh wow. I don't want to be on hormones because that causes breast cancer. And that's not because these people are not intelligent, it's because they've been told…”
[00:16:05] Dr. Haver: It's going to ake everybody being on board. It's going to take years, but I am so proud to be on… I can't believe this. I'm just a regular OBGYN. There's nothing special about me and, but I…
[00:16:19] Dr. McBride: Oh, there's so much special about you.
[00:16:20] Dr. Haver: I'm kicking the door down on this I feel like… And it's probably the thing I'm most proud about in medicine, and I've delivered about tens of thousand, over 10,000 babies. I've done thousands of surgeries, all good stuff. But I feel like this is the biggest impact I can make for women's health ever.
[00:16:40] Dr. McBride: I think you're making a big difference. I mean, it's amazing to me how menopause is having this moment right now. My friend Sharon Malone, who's a dear friend and colleague, was just on Oprah talking about menopause. I mean, thank you Oprah, for shining a light. My friend Rachel Rubin, our mutual friend, Kelly Caspersen, I mean, we're talking about sex, we're talking about vaginal lubrication, libido.
[00:17:01] We're talking about taking control of our health kind of for the first time in a long time. I don't know if you think it's related to COVID and to me COVID laid bare our vulnerability to narratives that aren't always rooted in truth. COVID laid bare the vast marketplace of sort of pseudoscience and weird stuff.
[00:17:24] It also laid bare how vulnerable we are as consumers of the healthcare industry. And how we really need to know what questions to ask. And so then I think, that's where I came in. I started writing and podcasting and you started doing your messaging and it's, I think people are really glad to have people they trust without any sort of agenda.
[00:17:42] Dr. Haver: Social media for me opened my eyes to how much misinformation as far as menopause care, how much disinformation and misinformation was out there. And then one of the caveats of this menopause explosion and what the New York Times touched on is the gold rush. And so my… I live in the menopause metaverse, I call it, and my social media feed is just filled with everything menopause.
[00:18:13] The wackadoodle companies that are coming up with miracle cures and vitamins and promising you're getting your unrealistic expectations of what this one little herb or something can do and get your life back and lose weight and get your sex life back and all this stuff. And none of it is founded in any evidence.
[00:18:32] They're marketing to a very vulnerable population. They're desperate and willing to try anything at this point because they can't get it from, most of them can't get it from their healthcare provider, and so a lot of these new companies are popping up and really exploiting this very vulnerable population, and it makes me insane.
[00:18:50] Dr. McBride: I know. I feel like wellness is a word that I think MDs and medical professionals should embrace, right? Like, what else am I doing other than helping people be well? But the wellness industry is taking advantage of women's vulnerabilities, insecurities and lack of access to the truth. And then it's fleeing them and giving them false promises. Not always. I mean, there's some good actors.
[00:19:16] And I believe in vitamin supplementation if you're deficient in something in addition to getting your nutrients through food. But I think we agree that there's no sort of supplement that's going to kind of fix your broken marriage and your low libido that stems from sexual trauma or… we have to do the work, we have to do the hard job of looking at these parts of our lives that doctors unfortunately haven't really countenanced and we have to understand that the treatment for menopausal symptoms and the way to prevent the downstream cardiovascular, cognitive, and bone related health problems that stem from the absence of hormones is hormone replacement therapy.
[00:19:56] Women are entitled to a conversation with their provider about hormone replacement therapy. Whether or not they take it is a different story, but in general, the benefits of hormone replacement therapy outweigh the risks in women who are within that 10 year window from their last menstrual cycle
[00:20:11] Dr. Haver: Right. And when a patient leaves my clinic, now again, I have a background in nutrition. I'm certified in culinary medicine. I can do this with confidence in myself that I know what I'm doing. I give them what I call the menopause toolkit, and so the first thing we address is nutrition. I'm lucky enough that I have a body scanner where I can measure muscle mass.
[00:20:34] All of this is all so intertwined, visceral fat, body fat. So I give them very direct nutritional recommendations based on their body composition. We talk about hormones—pharmacology, hormonal pharmacology, and non-hormonal pharmacology based on their symptoms. We talk about supplementation based on what their nutrition profile looks at.
[00:20:56] We talk about stress reduction, we talk about sleep quality, and every single one of those things is important to turn that wheel so that you can have the best healthspan and lifespan when a patient comes to my clinic. Yes, she's suffering, but her goal is not to have a bikini. Most of them… they don't care about bikinis anymore.
[00:21:14] Sure, that'd be great. But they're more looking at their parents and what themselves and their siblings are going through taking care of parents with chronic disease. When I have a patient who is caring six or 10 years for a debilitated parent or grandparent, it shapes their lives and they are so motivated. What can I do now to keep me from doing this to my children, to my loved ones, to my nieces and nephews. I want to live the most independent, healthiest life that I can. So I'm not gonna burden the people I brought into this world with my disease and illness. Now, there's no guarantees on that. They're like, “how can I stack those cards in my favor?”
[00:21:55] And I said, okay, let's get started. Nutrition, exercise, pharmacology, sleep, stress. It all works together to get you where you wanna be.
[00:22:04] Dr. McBride: You're absolutely right and it so dovetails with the way I talk to my own patients and the way I write that sleep is arguably the best chemical boost you can give yourself—getting good sleep. Now, it's easier said than done. I mean, just telling someone to sleep more is not the end of the story for most people. But managing stress, having brain space to be mindful about our eating, our relationships, being in touch with how we feel, sort of being in the driver's seat, if you can, of your everyday habits. I think all of that relates to symptoms of menopause. It also relates to just our everyday health.
[00:22:44] I think you're right. You look at our parents, our patients in their middle age often look at their parents and they see if their mom has osteoporosis and maybe some cognitive decline. Their dad may have cardiovascular disease or vice versa. And those are not a hundred percent preventable of course, but it's pretty incredible what hormone replacement therapy will and can do if you pair it with appropriate lifestyle modifications and you pair it with someone who's a good coach and a good guide because it's not enough for me to say, eat less red meat, Exercise more, sleep eight hours, manage your stress, take hormones, Good luck. I mean, first of all, I don't do all that stuff well all the time myself. Most humans need a trusted guide. They need structure, they need support, they need follow up, and they need cheerleading, and they need data and evidence and facts to guide their behavioral changes.
[00:23:36] How does your program work? Like tell me, if you have a new patient who comes in, you do an assessment, let's say you recommend hormone replacement therapy. How does that look? I mean, do you typically recommend the patch? Do you recommend the ring? Do you recommend oral hormones? Tell me about the menu of options for hormones.
[00:23:54] Dr. Haver: So I do stick to the FDA approved options. Estradiol is the number one hormone that I prescribe. So there are synthetic estrogens on the market. There's the conjugated, equine estrogens on the market. There are also different compounded options because compounding is not subject to regulation. It's not subject to testing. It can be very variable. I really want to stick to—I know when I pull it off the shelf, it's what I use for myself. There's a 98% chance of what they say is in that box, is in it, and that my patient's going to get a steady state. I usually go with a transdermal option over oral for estradiol because the first pass effect of the liver, which you and I know, when that estrogen bump hits the liver, it upregulates our clotting factors. So there's about a seven out of 10,000 women increase. So not very much, but still seven women who will have a blood clot. I can negate that and put you back to your baseline.
[00:24:55] Not saying you will never have a clot, but I won't increase that risk with a transdermal option. And because of cost, affordability, and options, I usually do an estradiol patch. If we decide on progesterone as well, There's some wonderful new data that's come out looking at different progesterones, synthetic versus progesterone, which is what our ovaries make… I hate the term bioidentical because it's become a marketing term, not a medical term…
[00:25:19] Dr. McBride: Thank you. Oh my gosh. Thank you.
[00:25:21] Dr. Haver: Women are getting sold a bill of goods and they're being told lies and they're being told the most ridiculous marketing that, oh, buy BHRT… I'm like, I don't use that term. I talk about estradiol and I talk about progesterone. I do not pick up a phone and call another physician and talk about bioidentical. That is, I would be laughed out of… I think people meant well with it, but it's turned into this crazy marketing term to get you to buy their product. So for progesterone I do the oral micronized progesterone. It has the best safety profile for breast cancer.
[00:25:57] Actually, in the latest studies, no increased risk of breast cancer. It was the synthetics. So I tend to avoid those as much as possible. So for myself, I use an estradiol patch and I take my oral progesterone at night. I still have my uterus. For me, I find progesterone sedating, which is a benefit because it helps me with sleep.
[00:26:17] Now, if someone is also having severe vaginal atrophy, I look at vaginal preparations. I love a vaginal ring. Nobody can afford it. It is top tier for most insurance plans. It's a wonderful method of delivery. I think it's amazing, but again, cost is a problem. So for vaginal estrogen, I tend to stick with the vaginal estrogen cream, which is generic and is very affordable for most patients if we decide she needs testosterone.
[00:26:47] And I pretty much only prescribe that in a case of hypoactive sexual desire disorder. There's not enough evidence yet for me to prescribe it for other reasons I don't. Everyone's testosterone is low, guys, everyone, you don't even need it checked if you're menopausal, half of your testosterone unless you have a tumor.
[00:27:06] And so if she's suffering from HSDD, then we discuss different options, the vii, the adi, the testosterone, if she chooses testosterone, because I don't have a great FDA-approved option. And it's very difficult for my patients to get the man's version because they only need 1/10 of the dose and they have to break the packets open and it's just Complicated. I will do the local compounding pharmacy to get some testosterone for them.
[00:27:30] Dr. McBride: So helpful. So I wanna ask you a couple questions and just to clarify for listeners, vaginal estrogen, in my humble opinion, I wonder if you agree topical estrogen or just vaginal estrogen in a tablet form that is not systemically absorbed, is just topical to help with vaginal dryness. It also can help with urinary continence. It can help with muscle tone in the pelvic floor if paired with PT or just Kegels. That should be in my opinion, over the counter. That should be non-prescription. It should be something women are…
[00:28:01] Dr. Haver: Yes, and I believe it is in the UK now.
[00:28:04] Dr. McBride: And even for women who have had breast cancer, it's, and look, talk to your primary care provider, your OBGYN. Don't take my advice on the internet, because I'm not your doctor necessarily, but I think it should be over the counter when you talk about vaginal estrogen, like a femme ring. The femme ring is the vaginal estrogen formulation. That is systemic hormone replacement therapy. The hormone replacement therapy we're talking about is to help with not only the symptoms locally, but also the sort of whole person, the bone density, the cardiovascular risk protection.
[00:28:38] So yeah, you're right. The femme ring is extremely expensive, but if someone's insurance happens to cover it, the femme ring, there's a nice way to go with the estrogen, and then you have to do the progesterone. In addition, if you have a uterus, you have to take progesterone with estrogen. Those are the two train tracks, because without progesterone, estrogen alone can stimulate the uterus and cause uterine cancer.
[00:29:01] So that's sort of the mantra. Testosterone, as you said, is sort of out of the box a little bit, but it is becoming clear that it's good for hypoactive sexual desire disorder. I do have patients asking me about it because they're like, “What about belly fat, muscle mass? Can I use testosterone for that?” I know you have this wonderful program you're doing on Instagram with the belly fat challenge, and you're doing this on the heels of your Galveston diet. So tell me about testosterone for women a little bit more if you could vis-a-vis metabolism muscle mass.
[00:29:31] Dr. Haver: So one of the phenomena that we know about in body composition changes through the menopause transition, we see an acceleration of body fat deposition. So it's kind of steady state and then whoop goes up in perimenopause and we see an increasing of the rate of muscle loss with age. It's called sarcopenia, which is the natural loss of muscle mass with age, and you have to combat that with consistent resistance training and adequate protein intake.
[00:29:57] There's no way around it. You are going to lose muscle if you don't do the thing. And that's just your body breaking down. And that muscle is so much more important than I ever learned in school. It is controlling our insulin resistance. It is controlling our strength and functionality. And so I am one of those girls who was genetically low muscle.
[00:30:16] I was always lean. But lean to me means muscle. I didn't have very much growing up. I could never do a pull up. I still can't do one. And so there's some thinking, so I'm using testosterone for myself off label, and I'm very clear about that because I'm genetically predisposed to low muscle mass. I measure it every day. I'm about the 90th percentile and I wanna hang on to that. So I'm doing a very low dose of transdermal testosterone in order to help my efforts of protein intake and resistance training to hang on and possibly build some muscle. So my levels are physiologic. I check my levels every three to six months.
[00:30:56] I think the last one I was 47. And so in our natural lifespan, When we're our reproductive height, when our libidos were on point, your testosterone level is never above 70, and some of these pellet companies are recommending that you be super physiologically dosed with no evidence to support it.
[00:31:18] I have had patients come and say, just check my level. My pellet should have worn off six months ago. They're still out of 300. That is men start at 246. Okay, so I asked the patient, okay, let me just make this clear. Are you transitioning? I fully support that. If this is what you're doing, I'm not the right doctor to help you through this, but, and they're like, no, I'm like, your levels are at a transitioning level.
[00:31:41] I don't have clinical evidence to support a super physiologic dose of testosterone for patients. And that's what's being sold to them by a lot of these camp bonding companies.
[00:31:53] Dr. McBride: So you're saying the data are not there yet, but there's enough evidence in your mind to use it at a physiologic dose to combat sarcopenia, which is low muscle mass. In addition to using it off label for people with low sexual desire, low libido.
[00:32:11] Dr. Haver: Yes. So we have great studies for menopausal women, and testosterone clearly showed a benefit. FDA has not picked up those studies and that work hasn't been done yet. It takes a pharmaceutical company saying, it's worth it for me to do this, and they're not doing it because it's, it's all about economics and there is ot a lot of money in it for them, which is why we don't have an option.
[00:32:34] Dr. McBride: Right. Let's talk diet and nutrition and what happens to our bodies around menopause. I've just gone through menopause myself. I'm on hormone replacement therapy. Woohoo. It's fantastic. I mean, my symptoms weren't that dramatic, but I think what happened was when I went on hormone replacement therapy, I just felt like myself.
[00:32:54] It wasn't like I could name what it was. I mean, I had some hot flashes, night sweats weren't bad, but I don't know, I just slept better. I felt like myself again. But nutrition, so patients commonly come into me around perimenopause in their late forties, early fifties saying, my belly fat has increased. I've never had belly fat there. And they're just, their body composition has changed and they find it harder to…
[00:33:20] It's true that estrogen in the absence of estrogen makes it easier to accumulate weight in our middles typically, and then it increases our risk for insulin resistance or pre-diabetes or diabetes.
[00:33:33] So what are you counseling patients? I know it's not a one size fits all prescription, but what are you counseling patients in general about how to combat that metabolic shift and the weight distribution?
[00:33:44] Dr. Haver: So there are certain behaviors and patterns of eating that we know through studies that for women in their menopausal journey, are going to lead to less accumulation of visceral or belly fat. When we say visceral fat, I want to be clear. So we have the fat, we've known our whole lives, subcutaneous fat.
[00:34:03] It gives us our breasts, our butts, our curves, our cellulite. We don't like it. It's cosmetically distressing, but in, in usual physiologic amounts, it's not dangerous. Okay, visceral fat is different. That's the fat inside of our abdomens and our wrapping around our organs. That at a level, at a certain level starts leading to inflammation.
[00:34:21] It produces cytokines, it's linked to cardiovascular disease, stroke, diabetes, et cetera. And we see a rapid accumulation of this fat in the menopause transition due to multiple factors, but leading off with decreasing estrogen levels. So, what can we do about it? So number one, women who have 25 grams or more of fiber in their diet per day have a much lower risk of visceral fat, and there's probably several reasons for this. It slows down the absorption of glucose into our bloodstreams, which lowers our insulin levels. It keeps us full longer. You're less likely to overeat or make different choices.
[00:34:55] Number two, having a diet that has less than 25 grams of added sugar in your diet per day—less visceral fat and added sugars are the sugars in cooking and processing. And I'm not talking about keto, so I'm talking about the sugars that are found naturally in fruits, vegetables, dairy, they come in a package with fiber, with other micronutrients, with other things that keep you healthy and slow down their absorption.
[00:35:21] It’s Very different from drinking a soda, and that's the number one source of added sugar in the United States in women's diets is beverages that sugar is instantly absorbed. It instantly goes into the bloodstream, causes a spike in glucose, and the concomitant rise in insulin levels, which then drives fat to the abdomen.
[00:35:37] The whole thing happens so fast before you even realize it drives your blood sugar down. Boom, you're hungry again. And so keeping those added sugars less than 25 grams per day. Not to say you can never sip on a soda or have a cookie, but you have a budget. And if you can keep it less than 25 a day, you're going to have less visceral fat and less ensuing health risks because of it. Third, there are some supplements done, checked on, menopausal women that seem like they were helpful. Number one is eating something rich in probiotics every day. So that could be yogurt, kimchi, miso, tempe, whatever… chinese pickles, there's lots of options, but the study that was done in menopausal women was actually done on supplementation, because that's easier to control and study is give someone a pill versus have them eat a tub of yogurt.
[00:36:25] So, when the study was done on obese, menopausal women with hypertension, so the weight loss was the same. They put them both on calorie restricted diets, but added in a probiotic supplement for Group B, and the supplement group had less visceral fat, so they did their visceral fat measurements, and they also had lower blood pressure.
[00:36:44] So keeping the gut microbiome healthy, both through fiber, which we talked about earlier and with probiotics, restocking the pond, as I call it, can be really helpful. Turmeric supplementation or eating diets rich in turmeric, not so typical in the US. People are now drinking turmeric teas or adding it to certain things, but turmeric supplementation, especially if you add a black pepper extract, can be really helpful.
[00:37:06] Zone two training. It's getting real with Peter's book, Peter Attia's book. It's getting really popular right now. Zone two training is training below the level that you can talk through, so like when you're a little bit breathless and so there's multiple, you can google different ways to calculate what that is.
[00:37:22] 220 minus your age, 60 to 70% of that is one thing that patients use. I wear a heart rate monitor usually, and so I know what my maximum heart rates are and I can do the calculation from there, but 150 minutes a week of zone two training is really helpful in that, and resistance training is important as well.
[00:37:40] Dr. McBride: Okay, so to summarize these pearls of wisdom we're talking about ideally getting at least 25 grams of fiber a day. Ideally less than 25 grams of added sugar a day. We're talking about supplements based on your unique profile and health issues, and we're talking about resistance training and 150 minutes of exercise a week, building that muscle mass, keeping that motor running. In addition, we talked about sleep stress management. I mean, that's a good kit. I mean, it's a lot to do. You know, when I talk to patients about these kind of lifestyle modifications, they often aspire to these things. They aspire to sleep more or drink less alcohol.
[00:38:19] Eat less sugar. One of the challenges is minding the gap between our best intentions and the execution, as I say to patients all the time,even walking around your block for five minutes after work is better than nothing. While you're on the phone, maybe do a couple squats or wall sits.
[00:38:38] Notice how you feel if you take a week off of alcohol. I decided to take May off of alcohol, not because I have an alcohol problem per se, but just because I feel better without it. And it really does take at least a week in my mind to kind of notice the effect. One night's not gonna do it. So my advice to patients is just small, incremental bite-sized changes. Don't try to make wholesale changes in every aspect of your everyday health because you just won't do it.
[00:39:08] Dr. Haver: Exactly. I say, we have the rest of your life to figure this out. Let's take this one step at a time. Here's the ultimate plan. We're building a house here, so first we have to lay the foundation, then we're gonna put up the studs. Then we're gonna, you know, like we have to take this step-by-step. We don't want you to be overwhelmed. We don't want you to feel like these are new habits. We're building one habit at a time.
[00:39:29] Dr. McBride: That's right. That's right. Mary Claire, thank you so much for joining me today. How can people find you on the internet? In your clinic, like how can people find your wisdom and expertise?
[00:39:41] Dr. Haver: So we have tons of blogs packed with information on how to advocate for yourself at your doctor's visit and you know what tests to ask for. There’s lots of nutrition information at our website at galvestondiet.com. You can also find me on my biggest social media channels on Instagram and TikTok.
[00:40:06] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you liked this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected].
[00:40:28] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
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You can also listen to this episode on Spotify!
Did you know that all children, regardless of genetics, are at risk for substance abuse?
Jessica Lahey is a New York Times bestselling author, mother, and parent educator on teen substance use. Her most recent book, The Addiction Inoculation, is a practical guide to help children grow up to be healthy and addiction-free.
On this episode, Jessica sits down with Dr. McBride to discuss her own path to sobriety, the myths about substance abuse in adolescents, and how to help kids feel comfortable setting healthy boundaries.
This is a must listen if you’re looking for ways to talk with your kids, grandkids—or yourself—about alcohol. Feel free to share this episode with others who may be, too.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, and review the show!
Transcript of the podcast is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.
[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://lucymcbride.substack.com/subscribe
and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
[00:01:01] My guest on the podcast today is Jessica Lahey. Jessica is a New York Times bestselling author, mother, longtime teacher and educator for parents and teens on the subject of substance use and overuse. Her most recent book, the Addiction Inoculation, is a crucial resource for anyone who plays a vital role in children's lives, from parents and teachers to coaches and pediatricians. Helping raise kids who will grow up healthy, happy, and addiction free. Jessica, welcome to the podcast.
[00:01:35] Jessica: You are so welcome. I'm so happy to be here.
[00:01:38] Dr. McBride: I'm really happy to be here too because you and I were talking before the show started recording about how medicine in the current landscape is failing people. It treats people like a set of boxes to check, like humans are a bag of organs. We cattle herd, we box check, we move people along the conveyor belt, when health to me, and I'm sure to your husband, who's also a doctor, is rooted in the relationship with a patient, is founded on trust. And particularly when we're talking about complex issues like substance use and overuse, it requires time to get to know the patient and then unlock those complicated stories.
[00:02:25] So, this is why I'm thrilled to have you here because it's clear to me that this is not just your job, but this is who you are. So I'd love to talk first about your story and how you became interested in substance use.
[00:02:39] Jessica: I couldn't avoid it because I was raised in a home with someone with substance use disorder. One of my parents and one of my parents was raised with a person with substance use disorder and so on and so on, and so on and so on. And when I first got sober, On June 7th, 2013. Not coincidentally, my mother's birthday, I got blackout drunk at her birthday party.
[00:03:03] My very first thought was, okay, well hold on. If I'm part of this long legacy, and by the way, my husband is part of a very long legacy of substance use disorder, how on earth do I make this stop for my kids? I mean am I just, are they just destined to carry? And I had so many questions about genetics and risk factors and all that stuff.
[00:03:27] And more than that, I had also been a teacher for 20 years. And after I got sober, I started teaching in an inpatient recovery center for adolescents. And I wanted to understand very specifically, how those kids ended up there, what could we could have done differently, both from a parenting, from a social, from an educational perspective, how those kids ended up there.
[00:03:50] And then looking at my own kids, I got sober when they were nine and 14. And I really just needed some answers. And I was hearing, most of the information I had in my head was myth. It was magical thinking. It was myth, it was rumor. I needed to understand, if we give kids sips when they're younger, does that do anything about helping them learn moderation or should we be aspiring to be like those European families that we talk about so much?
[00:04:19] And anyway, so all of that stuff, I needed answers. I have the coolest job in the world, which is to get curious about topics and then get paid to research the heck out of them, and then translate that research for people who don't wanna dive in and research for two years to get the answer to a topic.
[00:04:36] So my job is not just… I'm a writer, but I'm at heart, a teacher. I mean, not just to kids, but now I get to go out into the world and translate all of this stuff. And if there's nothing I love more, it's helping people think about topics that freak them out. Whether that's letting your kids fail with Gift of Failure, whether that's substance use prevention stuff.
[00:04:59] It's the reason that I've stuck with this substance use prevention stuff, because it’s just so hard to get people over the shame, the guilt, the fear, the denial in order to talk about this stuff. So that's one reason that I make daily videos about this stuff. I'm out there speaking to lots and lots of people, and sometimes it's an uphill battle, but it's really, really fun.
[00:05:23] Dr. McBride: I can tell you're enjoying it and you're so effective at communication. I'm the same way. I love complicated patients. I love the layered kind of kernels of people's interiority and how their thoughts, feelings, and behaviors are interrelated and then explaining it to people. I also love tackling topics that tend to freak people out, like death and dying, delivering bad news, like somehow that's like my Super Bowl. And I think one of the reasons is because, at least for me, I see the fear in people's eyes and I see the shame that they carry and then being able to kind of convey a message to people that is, that they can wrap their arms around is really gratifying. When it comes to substance use disorder, I think a lot of parents are freaked out.
[00:06:12] I think they read the headlines. They see how pre pandemic, we had an epidemic of diseases of despair, including substance use disorder that is only accelerated during the pandemic and they don’t know what to do. And they know their kids in their adolescent years are trying alcohol, drinking in kids' basements.
[00:06:30] They're kind of looking at what other parents are doing and not knowing who to trust. And so I'd love to hear from you what are the common myths that parents tend to hold in their minds about substance use disorder in adolescence?
[00:06:47] Jessica: Yeah, I think this is really important because it's also the myths that get translated to their children. And the big ones are things like, first of all it's a fait accompli—kids are going to drink anyway, so I might as well teach them how to do it responsibly, either because I have beer at my house and I take away everyone's keys, and at least they'll be safe.
[00:07:06] That sort of just fatalistic, it's going to happen anyway because that's simply not true. The numbers are so much lower than people understand, and I get into that. In the book, there's this thing called pluralistic ignorance, which is we tend to overestimate in the case of alcohol, for example, how much people tend to drink, the people around us and how invested they are in having alcohol around.
[00:07:28] And we all tend to overestimate that. So that sort of fatalistic thing, the whole, you know, I really want my kids to be like those European kids. So therefore if I let my kids have sips at home, let them have their own beer, a little bit of wine, that kind of thing, it'll somehow teach them to be moderate drinkers and not freak out when suddenly alcohol is available to them at college or whatever.
[00:07:51] And that's wrong for so many reasons. I mean, the European Union as a whole, based on data from the World Health Organization and specifically World Health Organization Europe has the highest level of alcohol consumption in the entire world, and the highest level of deaths and illness attributable to alcohol.
[00:08:10] Yes, there are exceptions, and that's a fantastic conversation to have as well, because that's about outliers based on the fact that those countries tend to have very particular community standards around public drunkenness. So the outliers tend to have to do with community pressures, and that leads to a great conversation of family culture, school culture, city culture, all those kinds of things.
[00:08:33] And then, the idea that our kids don't listen to us because that's just not true. Even as kids get into college, they report that their parents tend to be their preferred and most trusted source of information for especially health, personal health, that kind of stuff, that kind of information. And finally, I want to also, I think it's really important to remember that substance use disorder and substance use are two different things. Lots of kids can try substances and not go on to have a problem with substances over the long run. And it's important to understand from an objective perspective what those risk factors are so that you can say, oh, my kids are at higher risk, or this puts my kid at higher risk, so what do I do specifically to deal with that. And then finally, I think it's also important to remember that yes, substance use disorder, we're having a crisis right now with mental health and stuff like that. And substance use disorder or substance use can be one way to cope with that. But prevention works. Effective prevention works.
[00:09:31] And we're at, we've seen a 10 year decline really now 15 year decline in most aspects of substance use in adolescence. And that's because prevention works. And in order to do that really great prevention work, we have to be objective about risk factors, and we need to realize that adolescent brains are different from adult brains. I don't talk about adult substance use that often, except for when I talk about whether or not you should do it in front of your kids and what your messaging should be, because the adolescent brain is just different from the adult brain.
[00:10:06] Dr. McBride: Okay. I wanna talk a lot about the adolescent brain, having three of them in my own house. I welcome your insights. Actually, two are in college, but they do inhabit my house every now and then. But let's go back to the first myth for a second. The myth that parents, I think, believe quite often, and I have believed in some ways, which is that it's inevitable they're going to use alcohol, trying to stop them from drinking alcohol or experimenting with it in high school is kind of like stopping a 747. I think a lot of parents think, as long as we've had the conversation, then this is, this is the best we can do. What data is out there, Jess, to show that delaying your exposure helps prevent the likelihood of substance use disorder?
[00:10:56] Jessica: So first it's just important to remember that there are two periods of brain development that are the most important. They're just these massive periods of brain plasticity, and that's zero to two and puberty to around 25-ish, depending on the kid. So what we need to remember is that that development, that cognitive development that's going on, and that brain development that's going on from puberty to 25-ish, we don't fully understand all of it, it is massive. It's happening all over the brain. It's happening with lots of different centers. The executive function part of the brain, the upper brain is connecting to the lower brain, and anyway, that needs to happen as unimpeded as possible. What we do know is that the younger a kid is when they first initiate their substance use, the more likely they are to have substance use disorder during their lifetime.
[00:11:46] So for example, if a kid starts in eighth grade, it approaches a 50% chance of developing substance use disorder over their lifetime. If they start in 10th grade, it goes down to around 20%, a little bit less than 20%. And if you can get them to 18, we get so darn close to 10%. It’s important to delay, delay, delay. So that's one reason. Not only are we lowering their statistical risk of substance use disorder over their lifetime, and yes, there are some confounders in that data. There are confounders. I mean 90% of people who develop substance use as an adult report that they started before the age of 18.
[00:12:26] And of course there are issues in there that we can't control for—the social determinants and all that kind of stuff. Families that have more alcohol around are gonna have kids that are more likely. So there's all of that as well. But this is what I'm dealing with in terms of the statistics.
[00:12:42] Also remembering that the development, the longer a kid goes without ingesting anything that messes, whether it's with your dopamine cycle or fills up receptors in your brain that are, should otherwise have naturally occurring neurotransmitters in those receptors, because we're introducing them through drugs and alcohol. The brain just needs to develop as unimpeded as possible for as long as possible. So we're protecting their brains and we're lowering their risk of substance use disorder over their lifetime.
[00:13:11] Dr. McBride: It makes sense in a lot of ways. The way I think about it is that the longer you give adolescent brains to ripen on the vine, and the longer you give kids who are dealing with a lot of complex thoughts, feelings and emotions and genetic predispositions, the more chance you give them to find and practice coping with hard thoughts and feelings. You just give them more opportunities to realize that they like drawing, they like being outside to play sports, they like laughing with their friends, they've realized who their intimate friendships are and where they can go to put a lot of thoughts and feelings instead of the default mode to alcohol, which for some kids, as we both know, is a occupational hazard for our kids who are in distress.
[00:14:02] Jessica: And that's really apparent when you see what happens to a kid who has substance use disorder. They come to rehab. We remove the substance they're using as their coping mechanism. Suddenly you have kids with unresolved trauma. I mean so much. When we talk risk factors, you know, trauma is a big part of it.
[00:14:21] So suddenly we have these kids that have been using this one and only coping mechanism for so long that they. Not only don't have coping mechanisms for that trauma, but they don't have coping mechanisms for interpersonal disputes, for just feeling anxious. All of their coping has been through using the substance instead of actually learning a real coping mechanism, which is why we often talk about kids in recovery as having been—in some ways not always—having had their development arrested at the age at which they started using the substance and. I don't agree with that fully, but what I do [00:15:00] know is that it does arrest their ability to learn prosocial behaviors, to learn coping mechanisms, to learn how to as we often hear from, for example, Dr. Dan Siegel, integrate their upper and lower brain, and figure out how to be slightly outside of their emotions as opposed to living completely inside of their emotion and reacting from their limbic system, from their lower brain and not engaging that upper sort of more rational part of their brain. Yeah, it's tough.
[00:15:31] Dr. McBride: I just had Lisa Damour on my podcast.
[00:15:33] Jessica: She's fantastic.
[00:15:34] Dr. McBride: I love her too. And we talked, as you would imagine, about the rainbow of emotions that adolescents have and how complex they are and how they don't have necessarily in their teenage years, the vocabulary with which to discuss feelings. They don't have the interest always in talking about their feelings, and they don't even know they're having them sometimes.
[00:15:55] I have this poster in my office. That's the periodic table of emotions. I have a version at home too. It's like the periodic table of the elements, but it's emotion. So instead of believing that we have happy, sad, mad, we have rage, we have jealousy, we have envy, we have fear, we have this whole rainbow.
[00:16:19] So my kids tease me about it because they're like, oh my God, there's mom with the rainbow of emotions again. But then I see them when I'm not looking like my son and his girlfriend kind of being like, “hmm, I'm feeling kind of vulnerable today.” So what is my point? That it is a natural human instinct, whether you're a teenager or an adult who's experiencing complex emotions that are uncomfortable and maybe not even named to seek out places and ways to soothe, and I think adults do this. This is why I have a job. But teenagers, without the vocabulary, without the tools, without the insight that you are helping them grow and that I see older teenagers myself, it can be a very complex landscape and they're… Alcohol in our culture is socially acceptable and legal, and so it seems natural that they would experiment with it, and then you're off to the races.
[00:17:11] If you have a kid who all of a sudden feels, wait a minute, my social anxiety has been quieted, my uncomfortable thought has been muted, my fear is less loud. And they don't even necessarily articulate it that way, but it makes so much sense that this is an occupational hazard of being an adolescent.
[00:17:29] Jessica: Yeah, there's definitely a camp—in any field there are camps—these little camps of people who believe various things. And there's the trauma camp, that substance use disorder response to trauma. There's also the developmental camp, and I think that's really important. I think the reason that I and you and Lisa love adolescents so much is because, we tend to have a deeper understanding of how their brains work, which is why I tell parents that the more you understand about your adolescent's brain, the better you can be at stepping back and not just reacting to some of the buttons that are being pushed.
[00:18:06] And I think that whenever I—in fact, I tell parents, whenever you're most frustrated with your teenagers, just look between their eyes at that spot, right between their eyes. And remember, that's the part of the brain that's not fully connected yet, and that what they're doing in terms of their adolescence is designed to make kids want to push out and to individuate, but also to try new things.
[00:18:30] What's so cool about that? In trying new things in seeking out novelty and yes, sometimes novelty comes with risk. When they succeed at those things that they're trying out, when they build new skills, they're actually boosting their dopamine and boosting dopamine through… Kids are constantly craving dopamine. They want, we all want to feel good, we all want to have that feeling of mastery, inhalation, and all that sort of stuff. But if we want our kids to seek that out in healthy ways and healthy places, we can push them towards positive risk on to skill building and building competence, and then they can sort of get that dopamine cycle going in productive ways.
[00:19:13] But I think the minute that you just sort of shut down and say teenagers are difficult, they're moody. I heard one time on a podcast on—it might have even been This American Life—it was definitely on NPR a long time ago when I was a middle school teacher, I heard a middle school teacher say, sometimes I let myself just think that we should send these kids away to some holding place until they're ready to listen and able to learn again.
[00:19:43] And it makes me bananas because the exact opposite is true, that for people that really love and appreciate and understand adolescence and especially early adolescence, the more we understand what an incredible opportunity there is for learning, and how much learning is actually going on during that period, and enjoy it more, the more we understand it, the more we have the potential to enjoy it.
[00:20:08] Dr. McBride: So talk to me about what do you see as a major differences between the adolescent brain and the fully formed adult brain as it pertains to substance use disorder and dopamine, et cetera.
[00:20:21] Jessica: Yeah, so I rely heavily on the Dan Siegels and the Frances Jensens and the Laurence Steinberg's to help me see—as Laurence Steinberg refers to—adolescence as an age of opportunity. And I love that because so many other people are talking about this a terrible time, but what you have to understand about the adolescent brain, and varying people describe it in varying ways, but there's sort of a mismatch between the part of the brain, the early developing part of the brain, the lower brain, the reacting part of the brain that is just like, you know, go, go, go, emotions, emotions, emotions and the part of the brain that's still getting connected that handles executive function and prioritizing of resources and time and all that stuff. And that mismatch seems to persist until just about the time that we want to freak out and give up on them. And then suddenly, and it's so cool being a teacher because you get to bear witness to these moments, and eighth grade is a great time for this.
[00:21:20] For example, I taught English, and so I taught a lot of literature that had metaphor and symbolism in it, and many middle school kids, not because they're dumb, not because they're smart, not because they're lacking anything, can't understand metaphor in a way that some, maybe some of their classmates can. But you don't stop talking about it just because they don't understand it yet. You just keep offering it. You just keep offering it in ways that are obvious so that the day that those neurons connect, you can see their eyes just go wide and they go, “oh. That's what she's been talking about.” And that same thing can happen with strategies for organization.
[00:22:03] I talk in the Gift of Failure about when my daughter finally connected this strategy for helping her remember things and actually remembering things and being able to go to school with her stuff. And had we been arguing about it for months? Oh yeah, of course. But it wasn't until for whatever reason, those neurons finally, finally decided to connect.
[00:22:26] And there have been times as a middle school advisor where, you know, I had a family once beg me to be their kid's middle school advisor, because I had been his brother's middle school advisor and his brother had made leaps and bounds during middle school. And I'm like, that's really sweet that you wanna attribute any of that to me and being his advisor. But it's just that his lower brain and his upper brain finally connected, and I was lucky enough to be there when it happened and capitalize on some of those moments. And that's what's amazing to know about the adolescent brain is that all of these things that we're being asked, we’re asking them to do that they may not be ready for.
[00:23:03] All of that creates stress, anxiety, a need for some kind of control over their world, and if we give them the autonomy and we give them the competence that they need, what ends up happening in their brain is they feel this, as I mentioned, the dopamine cycle lets them have this great burst of dopamine. If you wanna read more about that, please read Anna Lembke's Dopamine Nation.
[00:23:26] It's such a fantastic book. And on the other side, the less kids get to feel that feeling of self-efficacy, of competence, of skill building, the more helpless they feel, the lower their feelings of self-efficacy become, and the more they turn to things other than their own abilities in order to help themselves cope. And it's the reason I quote Chris Herren. Chris Herren, former Boston Celtic, ended up addicted to opiates. It's a fantastic story. Basketball junkie, if you ever wanna read it. And he goes out and speaks to kids a lot and he, I quote him in the addiction inoculation as talking about the fact that we tend to spend so much time talking about the last day of substance use.
[00:24:07] How far we fell, how disgusting it was on my mom's birthday on June 7th, 2013, and how ugly it got. But what we need to be talking about, especially when it comes to kids, is the first day, and he talks about that moment when a kid is at a party in a friend's basement, and why they don't feel like they are enough. They deserve to be loved. They don't deserve to take up space. They don't deserve to be here. What is it that makes them turn to substances? And I'm really lucky in that I get to talk to a lot of kids and hear what those moments sound like for them. And we need to help them feel like they're enough in those moments so they don't have to turn to something else.
[00:24:49] Dr. McBride: I wanna break that down and I first wanna just comment that. You know, I think a lot of substance abuse programs in schools focus on this on the last day, right? Like, they focus, they, they bring people in and try to scare the pants off of kids. They show images of drunk driving accidents and kids are supposed to go away thinking, “oh, I don't wanna be in a car accident. I don't wanna die.” But in my experience with teenagers, myself, as a physician and as a mother, that doesn't really work. And then we know the data are clear that scaring people doesn't work. We have to meet people where they are. And it's clear that, as you talk about so beautifully, the roots of a healthy program to educate kids and on substance use is social emotional learning. So can you talk a bit about that and how that relates to the prevention as individual parents who may be listening?
[00:25:45] Jessica: Yeah, so backing up, for example, in this country, only 57% of high schools in this country, and by the way, high school is too late to be starting this. Anyway, we need to be starting these programs very, very young, and I talk about that in Addiction Inoculation. Only 57% of high schools in this country have any substance use prevention program.
[00:26:02] And of that 57%, only 10% are based on evidence. On any kind of evidence of efficacy, that kind of stuff. So what we know about the best available substance use prevention programs is that they start very young, pre-k, k, and continue all the way through the end of high school. They are rooted in social emotional learning, refusal skills, building self-efficacy and self-advocacy, and essentially giving kids from a very early age, pro-social skills and coping skills, coping mechanisms.
[00:26:37] It's the reason that some have mindfulness programs attached to them and unfortunately, we're in this horrible position right now where we know these programs work. Oh, and also life skills, by the way. Life skills are a very important part of these programs as well. We know that social-emotional programs that contain health modules—making sure your bodily autonomy and safety and self-advocacy and stuff like that. We know those work. And yet, right now, For the first time ever, social-emotional learning is under attack because there's a faction of society that sees social-emotional learning as something that it's absolutely not, which is either indoctrination or identity and whatever. And it's really, really upsetting to me because without social emotional learning programs, which are just about building pro-social skills and skills that help us be a part of society and get along with other people and advocate for ourselves and all of this stuff that we know is so important.
[00:27:36] Ask kindergarten teachers, they repeatedly say those are the skills that if you were to look at kids and say, okay, that kid is probably gonna do really well, and that kid probably is not. It all comes down to pro-social skills and behaviors. If we do away with social emotional learning, there have been places I have spoken where I've been asked not to use that acronym because it's quote “problematic.” This is a disaster because this is what we know works for substance use prevention programs, and we abolish that at our peril. Any gains we've made in the reduction in substance use among adolescents, we're going to lose.
[00:28:15] Dr. McBride: I could not agree with you more. I mean, social emotional learning to me is about giving yourself permission to be human, to be flawed, and to have bodily autonomy, and as you said, the refusal skills and the ability to learn how to cope and function in the real world.
[00:28:34] Jessica: Self-regulation, collaboration. Well, and then if you look at risk factors for substance use disorder, we know that 50 to 60% of the risk lies in genetics. That's Dr. Mark Shook at the University of California, San Diego. We know that the other 40 to 50% is adverse childhood experiences, trauma, stuff like that, and then set.
[00:28:53] And of course, the social emotional learning stuff can help kids with that. But then on the other hand, we also know that child on child aggression, academic failure, social ostracism, undiagnosed learning issues, all of these other things are risk factors as well. And if social emotional learning programs help with so many of the things that can counteract social ostracism and help identify academic failure early on and can help reduce aggression between children. This is such an important part of the substance use prevention picture, and because we also know that self-efficacy is one of the most important things we can give kids and self-efficacy comes from the ability to self-advocate and self-regulate. It's all this self-perpetuating cycle that if we throw a wrench in there, sorry to mix metaphors, that we, this whole thing grinds to a halt and we have a whole bunch of kids who not only can't get along with other people, but don't have any coping mechanisms within themselves to manage their own stress. All that stuff Lisa Damur talks about with girls and Yeah.
[00:29:58] Dr. McBride: When I was growing up, it was just say no. That was the mantra.
[00:30:01] Jessica: And we know that doesn't work
[00:30:02] Dr. McBride: and it would be really easy to say no if you had the social wherewithal, the confidence, the emotional skillset to manage that moment when a kid asks you if you want a beer and you're an eighth grader…
[00:30:14] Jessica: Well, and that's not even enough. That's not even enough. So what we need are, they're ultimately called refusal skills. I sometimes call them refusal skills. I call them in Addiction Inoculation—the inoculation. There's a school of sociology called Inoculation Theory. It's essentially if we give kids the information they need in order to counteract messaging that's coming from other places, whether that's from liquor companies advertising beer to kids during sports, or another kid in their class. So let's say for example, you have an eighth grader who gets offered a beer. And the rejoinder to “no thanks” is, “come on. It's no big deal. Everybody's doing it.” If your eighth grader knows, well, it is kind of a big deal because here's what's happening in my brain and, and blah, blah, blah, and they know that it's not true that everybody's doing it. That in eighth grade, by the end of eighth grade, only 24.7% of eighth graders admit to having had more than a sip of alcohol.
[00:31:16] So if they have that information, it makes them feel more confident in their stance and makes them more likely to continue to stick with their rejoinder of, “no thanks. I'm good.” And that those refusal skills, that inoculation messaging is so important and we have to start that early and continue it through.
[00:31:37] So it's not just about the wherewithal, the emotional wherewithal to say, no, we need to give them the actual information to back that up so that they can feel more confident in their stance and they can have a reasoning behind their stance. And it's the reason, by the way, that of the entire book. There's a lot of things I loved about writing this book, but my favorite part, I didn't necessarily write. I asked adolescents to give me excuses they could use in public at a party or whatever that would help them save face and yet allow them to get out of using if they didn't want to. And there's two and a half pages of those in the book, and I'm so grateful to all of the kids that sent those to me because so many of them are brilliant and I wouldn't have come up with them on my own.
[00:32:21] Dr. McBride: Give me some examples. I'd love to hear, and for any parent who's listening, I would love to like have you flip to that page because if we can arm our kids with like just the words to use and ideas, then that would be great.
[00:32:36] Jessica: they are things like, “I can't, I get migraines” because we know that, for example, wine, alcohol is a trigger for migraines. “I can't, I have a sleep disorder.” We also know that alcohol is a major component of sleep disorders—it exacerbates sleep disorders. “I can't. I'm taking an antibiotic.” “I can't. My parents drug test me. Aren't they horrible?!” or “I can't, my mom breathalyzes me when I get home.” or even just in their own head. My son, who's now 24, when he was in high school, he admitted to me that while he doesn't say this out loud in his own brain, he's like, “I know that I'm at increased risk for substance use disorder, and my mom had to work so hard to get away from the pit of despair that she reached in her alcoholism. I think I'm just gonna not risk that for now,” or “I have an early practice. I can't.” “I'm the designated driver,” which by the way, makes you more popular with other people because you can help them get home safely and not get in trouble and not get pulled over. There's all kinds of things that we don't even think about.
[00:33:42] A lot of Asians have something that's like a flushing disorder that is actually, it's sort of a… it's not really an allergy to alcohol, but it is something that makes drinking alcohol quite unpleasant. So you can go with that. There are a few studies, there's all kinds of ways that you can get at this.
[00:33:59] It’s just not the best thing for me right now. And I think the big overlooked answer is, “nah, that's okay. I'm good.” No is always an acceptable answer. And even in in sobriety, I have to value my sobriety and my safety more than maybe the worrying about upsetting my host, if I need to go home early from a dinner party where I'm just not feeling safe anymore and my husband and I have a signal and we've got all kinds of exit strategies and stuff like that, but helping kids know that they're worth it, that they are allowed to say no and that, obviously we have to make sure they know that in terms of unwanted touching and having sex before they're ready, all of that kind of stuff, we have to sort of empower them, give them the self-efficacy they need in order to feel like they're entitled to say no to whatever the heck they want to if it feels like it's going to endanger their safety.
[00:34:56] Dr. McBride: And I do think kids these days are feeling more empowered to say how they feel to put limits down, to set boundaries. But of course, without the vocabulary and tools and the social support and the emotional vocabulary, it can be more difficult.
[00:35:11] Jessica: Yeah. And that why that's part of the dovetail also with Gift of Failure, is that we know that parents who are highly controlling of their children tend to have kids that lie to them more often, and also that don't feel heard because if you are from that school of thought of do it because I said so or because I'm the parent without attaching any of the why to it, then it's like the difference between saying, I would prefer that you not drink until 21 because it's the law versus I would prefer that you not drink until you're 21 because of the potential damage it can do to your brain and because it can raise your risk of, of substance use disorder over your lifetime.
[00:35:48] I'm a why kind of person. I need to know the why. Otherwise, I am not invested as a learner and many kids are the same way. Just telling them, because I said so doesn't tend to be a winning strategy.
[00:36:02] Dr. McBride: To what extent are parents, quote unquote, “responsible” for their kids' relationship with alcohol? I'd love to talk to you about genetics versus experiences. The whole trauma argument that…I'm sure you know Gabor Mate and his system, I mean, he's wonderful. I also take a little bit of an issue with the idea that it's all rooted in trauma. I also believe on the other side that trauma is a, is a big word and can mean lots of different things. Feeling unloved and unsafe in your home for whatever reason can be traumatic. It's not just the. Experience of say, you know, breaking your leg and being ambulanced to the hospital. It can be an uncomfortable experience.
[00:36:54] It's the way that experience is handled from the individual standpoint, and that can then lead to a predisposition towards unhealthy coping strategies. So talk to me about what parents are responsible for. How much is genetic and how much is environmental, because I don't think we know the answer, but I'd love your thoughts.
[00:37:17] Jessica: Yeah, so like I said, the, the figure we have on the genetics is about 50 to 60%, but then you add on top of that this added layer called epigenetics, which is a crossover between environment and genetics. Also it’s not just one gene. We're not gonna ever have this CRISPR technology where we're like, oh, we can flick that one gene out. Look. And addiction is gone. It's not like that. It's tied into personality, it's tied into chemistry. It's tied into so many different aspects of our environment. And again, epigenetics determines how genes either do turn on or don't turn on, that kind of thing. So then on top of that, the other 40 to 50% is yes trauma.
[00:37:56] Jessica: But there's all different kinds of trauma. If you read Lisa Damour’s Under Pressure, you understand the difference between stress, like there's little T trauma and there's Big T trauma. I think everyone on the planet should have to read Nadine Burke Harris's The Deepest Well, because average childhood experiences as originally defined by the CDC and Kaiser Permanente are really valuable, right?
[00:38:21] Because we know that people who have. People are more likely to have negative life outcomes in terms of health, mental health, all kinds of other stuff. If they've had various adverse childhood experiences and there's a really handy list, go google Adverse Childhood Experience and Quiz, and you can take the quiz yourself.
[00:38:38] However, it is not a complete list. The things that are on that quiz are a great starting place. For example, we know that physical and especially sexual abuse is a huge, huge glaring blinking neon sign risk for eventual substance use disorder. That's a huge, massive risk. So the adverse childhood experiences list of 10 things within categories comes close, but then there's also… it doesn't take into account Nadine Burke Harris's list, which can include things like systemic racism. Why on earth are we not counting that as a big T trauma because it absolutely is. There's a lot of debate right now around adoption, around all kinds of things that qualify as—can qualify as traumatic experiences for kids.
[00:39:24] So, and you should know about me that anytime someone says it is, All this or all that, I'm immediately suspicious as a journalist
[00:39:35] Dr. McBride: Well, I'm the same way. I mean, that's, that's it. I mean, everything is in the middle. It's not all nature. It's not all nurture. It's in the middle.
[00:39:40] Jessica: Well, and that's why, you know, there's an entire chapter essentially. What if I were to write about the peers chapter, you know, why did I include a chapter on the influence of peers in the book?
[00:39:49] Why bother? Because I could have just said, research shows that the more your kid's friends use drugs and alcohol, the more likely your kid is to use drugs and alcohol. Okay? Chapter over. But the problem is, it is a much more nuanced picture than that. And I tell the story in that chapter of. My son Ben had a friend who, Brian, that's his real name.
[00:40:08] He was insistent—the two young adults I profile in the book, Brian, and Georgia insisted that I use their real names because they felt this was just too important. Brian and Ben became friends. Brian had been already kicked out of one high school, then got kicked outta my son's high school for substance use and behavioral stuff and my, my kids stuck by him and all their friends stuck by him and I'm like, look, my instinct as a parent is you cannot be friends with this kid because if he does substances, you are more likely to do substances. In the end, that relationship was much more complicated and the fact that my son, Ben, and his friends stuck by Brian actually led to the moment where Brian realized on the second time he got kicked out of that high school and my son and his friends took him running on the last day, he was allowed to be on campus. Brian realized in that moment that was his turning point. That was his 100th piece of his puzzle where he said, it all has clicked into place and I see what I stand to lose, and my son benefited from the object lesson. The real scared, straight sort of object lesson, real life learned experience of, oh, this is what happens when you rely on substances in order to manage these other things.
[00:41:26] And here let's talk about those things. And PS the best part of that whole relationship was I said to my son, “Ben, look. I'm so pleased you want to support him and go visit him in rehab and all that stuff. Loyalty is great and a friendship, but if you're going to be friends with Ben, knowing what I know about the statistics, we're gonna have to talk about this a lot.”
[00:41:47] And that was something that became a standard conversation topic for us. How's Brian doing? How are you doing about Brian's… how do you think Brian's doing? How do you think…what are you seeing that works for Brian and what doesn't work for Brian? It gave us a proxy so that my son didn't have to talk about himself as much, which can be very difficult for teenagers. But it allowed us this proxy to talk about substance use and substance use disorder in the guise of Brian and gave Brian a launching off place for his, what became his recovery.
[00:42:19] Dr. McBride: It's so lovely and I really like the way you talk about Georgia and Brian in your videos and in your book, because it just helps parents, I think, hook into the realities of these kids' lives with empathy and compassion for their stories and great respect for their privacy. Obviously, that the fact that they wanted to share their stories means that they feel that this needs to be talked about more than it is.
[00:42:45] Jessica: Yeah, I can't count the number of times. I was like, no, really, let's do a pseudonym. You can choose the pseudonym. And even recently with Brian, I had to get in touch with Brian about something and I wanted to make sure that they were making that decision from a place—and they were [00:43:00] adults when they made this decision—but that they were truly making this decision from the perspective of, you know, I appreciate that. A lot of people have shame and guilt in that. There may be some persecution that I could face maybe in the workplace later if this got out, that this was me, but this is too important. It has brought some value out of everything I went through as a kid, as a child of an alcoholic, everything I went through as an alcoholic.
[00:43:25] And this education might help someone else. And I think that's really where Brian and Georgia are coming from, from this. And I talked to Georgia last week, talked to Brian two weeks ago, and yeah, they're doing great. They're doing so well.
[00:43:39] Dr. McBride: It's incredible. I'd love to now segue into talking more about you if I could because you are talking the talk and walking the walk. So had you tried to get sober in your life before that moment at your mother's birthday party?
[00:43:56] Jessica: I've had periods of sobriety because I was scared. Like, you know, I did that, I did that thing a lot of sober curious people do, and to make it clear, I'm so hopeful about where we are right now because I think a lot of people are realizing you don't have to rise to the level of completely out of control, homeless, DUI, all that stuff, getting fired from work. You can say to yourself, “man, I'm gonna try dry January and just see how it goes.” And then you realize, oh wow, this kind of feels better. And so I'm gonna keep going. You can stop drinking just because it's not working for you anyway. I was scared to death.
[00:44:30] I tried through the guise of long distance running like I used, running as a reason to stay sober, to not drink, and I would make all kinds of bargains with myself. When I was pregnant, I was sober. When I was training for big races, I was sober, but it just was starting to take over to a degree that I couldn't control it anymore on my own. And so the reason I talk about getting to a place where I know I needed help as a 100 piece puzzle is, you know, my dad on that morning, after my mom's birthday party was my 100th piece. But pieces one through 99 had to be there for all of that to click into place and form a big picture.
[00:45:13] And those early attempts at sobriety were pieces of that. And the beauty of all of this puzzle piece stuff is that I can't guarantee that my kids are not gonna develop substance use disorder, but all of this prevention stuff are pieces of that puzzle. So maybe they get to start at piece 65, where I started at piece 32.
[00:45:34] It builds those blocks. So I was able to get sober. I happened to get sober in 12 step and. There are lots of ways to get and stay sober. I happen to get sober in 12 Step, and my higher power is the people in those rooms and the people I work with at the rehab where I work now. I work as a prevention coach and sort of a recovery resource at Santa at Stowe.
[00:45:58] It's a recovery in Stowe, Vermont. It's medical detox and recovery, and they are my higher power. I can't show up for them. Unless I'm sober, I can't go do my speaking engagements. I can't do my daily videos unless I show up sober because then I'm being completely inauthentic and I would be hungover and miserable.
[00:46:18] But all of my stuff has been partially in service to getting control of my life back and being the parent that I know I need to be in order to raise two kids who might break the cycle of this.
[00:46:36] Dr. McBride: What I'm hearing from you is that. Your sobriety is rooted in the 12 steps. It's also rooted in the ongoing process of helping other people, which is one of the tenets of AA is passing on your knowledge and wisdom to other people and, and making meaning out of an experience, and I think you really are making a difference.
[00:46:55] I see people reading your book. I hear p people reading your book. I've had my kids listen to your videos, and not that they necessarily wanted to, but I have heard some good feedback because I think what happens when we talk about alcohol to adolescents is it often comes across as a parent as just a, a moralistic, judgmental, do as I say, conversation
[00:47:22] Jessica: And not necessarily do as I do, because if…
[00:47:25] Dr. McBride: not necessarily right. And then we go, poor gin and tonic. And they're like, Hmm. It's funny, one of my most popular posts on substack, like by a mile was the post I wrote called “Is Dry January a good idea? And I put it out on January one.
[00:47:40] And I mean, the answer to the question in my mind was probably what you wouldn't be surprised to hear, which is that sure. It's only though scratching the surface of the curiosity and compassion and empathy we need to have about ourselves and about the why, because you can put a fence around a behavior for 30 days, 31, I guess, in January, and then on February 1 you can go to the pub and get plastered or just start drinking again.
[00:48:07] The question isn't, can you give it up because you can…
[00:48:10] Jessica: I gave it up for a year.
[00:48:12] Dr. McBride: And for some people that's very hard, but the harder question is mining that interior landscape that is driving you to drink when you don't want to, if you're remorseful the next day, [and] you wish you hadn't done it. That is hard work, and it's much easier to put a fence around it for 31 days. I'm not saying don't do it. I'm saying do it and get curious.
[00:48:34] Jessica: One of my favorite speaking gigs is, and don't hate me for this, but every six months or so I'm at Canyon Ranch, either in Tucson or Lennox, Massachusetts, and they put me up and give me a discount on spa stuff for me and my plus one, and I do my talks. But the cool thing about Canyon Ranch is that there's no alcohol served there.
[00:48:55] And some people bring their own because they just can't be without it for a couple days. But there are plenty of people who go there and realize that they hadn't anticipated how difficult it was going to be for them to not have it there as an option. And, and then every—because Canyon Ranch was founded by someone for whom recovery is part of their story—there is a meeting there every single day at five and the people that often, and I often run those meetings and the people that show up at those meetings are often people who are like, “I don't really know why I'm here. All I know is it really bums me out that there's no alcohol here and I don't know what that's about.”
[00:49:29] So, you know, it's a
[00:49:31] Dr. McBride: great starting point.
[00:49:32] Jessica: Well, and also a lot of people are there either by themselves or with a spouse and don't know anyone else there. So they feel like it's a super safe place to go to a first meeting anyway. Either way, it's a really cool place to get to do the kind of stuff that I do. Because it's opening the door for them in a way that maybe they hadn't anticipated.
[00:49:51] Dr. McBride: Yeah, I mean it's self-discovery. I think about health as not an outcome, but a process of laddering up from self-awareness to acceptance to agency. I mean, the serenity prayer… I'm not in recovery, but people ask me if I am all the time. I mean from alcohol, I'm, I'm in recovery from other s**t that I do, but because I really understand and believe in the concept of the Serenity Prayer, which is accepting the things we cannot control, which is a lot, knowing ideally what we can control, and then understanding the difference and not spending so much time over here and shifting our energy and attention and curiosity to this spot.
[00:50:31] Jessica: You want to hear something ridiculous? This is so interesting. So two things. When the book first came out, it was first getting its reviews and stuff like that. I got one review where it said very specifically that I parroted AA stuff. So first of all, I did not use anything AA in the entire book except in one spot.
[00:50:52] I said, this is where something, for example, like the Serenity Prayer has been useful for me, and this is the restraints that we're dealing with when we talk about this stuff. Like that's why don't talk about AA because it is, the minute I refer to that, that is the only thing someone will hear. And then I'm just stuck.
[00:51:11] Dr. McBride: And they associate it with, oh, AA that's like my crazy Uncle Sal. I just drink a gin and tonic every night. What's it to you? So I think that your approach that is honest, empathetic, rooted in data, and that stems from your own experience of being perfectly imperfect is really valuable. And so I just want to say thank you for being here and thank you for doing what you're doing and God speed.
[00:51:38] Jessica: I am so grateful to you for just having this conversation. Every single time I have this conversation with someone, I get an email or a DM from someone saying, you know what? I'm scared too, and I don't know what to do. Or, I'm scared for my friend and I need to know how to help them. And so, you know, the more we talk about this, the more other people are gonna feel like they're allowed to talk about it too.
[00:52:02] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected].
[00:52:24] The views expressed on this show are entirely my own and do not constitute medical advice for an individual. That should be obtained from your personal physician.
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Juneteenth is a celebration of freedom and liberation. I can’t think of a better person to speak to the importance of self-expression, autonomy, and living without oppression than Nedra Glover Tawwab.
Nedra is a practicing therapist, relationship expert, and two-time bestselling author. She understands that health begins with individual freedom—and that healthy relationships require supporting each other's freedom, growth, and self-identity while maintaining mutual respect and healthy boundaries. Her books, Set Boundaries, Find Peace: A Guide to Reclaiming Yourself and Drama Free are born out of her philosophy that a lack of boundaries and assertiveness underlie most relationship issues. Today, Nedra sits down with me to discuss the physical and emotional health consequences of relationship drama—and the importance of self-awareness and acceptance in order to have agency over our life and health.
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[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I'm here to help people tell their story, to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://lucymcbride.substack.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
[00:00:58] Okay. Buckle your seatbelts. I am thrilled to be speaking today with two-time bestselling author, licensed clinical therapist, and relationship expert Nedra Glover Tawwab. Every single day, whether it's counseling patients in her therapy practice, or talking to her 1.8 million Instagram followers. Nedra is helping people create healthy relationships by teaching them how to implement boundaries.
[00:01:29] She has written two books Set Boundaries Find Peace and her most recent book, Drama Free, both of which are born out of her philosophy that it's a lack of boundaries and assertiveness that underlie most relationship issues. Nedra, I cannot tell you how happy I am for you to be here today. Thank you so much for joining me.
[00:02:02] Nedra: You're welcome. Thank you very much.
[00:02:04] Dr. McBride: As patient-facing providers, you and I both know that relationship stress, relationship drama, can affect people’s health. During the pandemic I witnessed patients coming into my office with headaches, migraines, back pain, high blood pressure, weight gain, alcohol use increasing as a result of a spotlight being shined on a troublesome relationship, or until they had to make hard decisions about parenting, caregiving, living through a trauma.
And so when I saw you on Instagram I knew I loved you at first sight, because you were there talking straight to the audience your 1.8 million followers about the relevance of relationships to our health and then you were dispensing practical guidance to this the drama and lean into the joys of relationships. And so thank you for doing that and thank you for being here.
[00:03:26] Nedra: You're welcome. The only time that, well, one of the only times I'll said, there's two times the only, one of the only times where I felt, oh my gosh, I think I'm having a panic attack, is when I was put in the situation of seeing a person who made me very uncomfortable. I was like, I'm about to have a panic attack… this is how much I don't want to see this person.
[00:03:54] My nervous system is on fire. My body is like run, hi, go. And it's not always, oh my gosh, I need to trust this, but I need to consider it. Right, because sometimes our bodies, our minds could be pushing us away from things we need to do, but there are other times where it's like warning, warning and we're like, okay, I'm going to do this anyway because I have to do it. And for me, in that situation, it was a warning to stay far away from a situation that was unhealthy because of past events.
[00:04:31] Dr. McBride: Another reason I knew we were kindred spirits, if you will, was that I saw you talk about adverse childhood experiences. So ACEs, as many people know, are events or situations or even relationships in childhood that have lasting effects on our health. In fact, there's no shortage of data to show that people who experience childhood trauma, whether it's physical, emotional trauma, experience higher rates of binge eating disorder, depression, anxiety, post-traumatic stress, and even cardiovascular disease.
[00:05:12] And so when I see someone like you who's helping people address the experience head on instead of meeting me when they're 50 and having heart disease, I think this is health, this is prevention. So could you talk to me, Nedra, about how you became a therapist and how the ACEs in your life perhaps informed that decision?
[00:05:36] Nedra: I was trained to be a listener. I listened a lot to my father in particular, talk about very adult topics, complain or, you know, ruminate or you know, do all, and I would just uh huh. I took it on as something that I had to do. I didn't know that this was a profession. I didn't even know this was something I was drawn towards, but it really shaped me into a person who. Was a good listener because with your parent, you're not really allowed to cut them off or stop them from talking. It was just like, oh, I have to listen to this person. And so it became a part of me with my peers, with other people in the grocery store who wanted to tell me random things.
[00:06:22] I'm like, “Uh huh.” And when I went to college, I thought I wanted to be a social worker who worked with children and you know, I got an internship and it was. In a therapy setting. And I realized that I actually like the side of listening where people actually want help. Not just people complaining, not just people ruminating or you know, saying, “Oh, woe is me.”
[00:06:47] It was people who wanted help with their situations. Now they may not all be at the same level of readiness, but they were certainly in the place of seeking. And for me that was a light bulb moment of, “Well, I have the training. I have the parent to fight training to do this. Perhaps this is an opportunity where I can really get into something that feels good to me.
[00:07:14] I felt really good being that person, that hope, [to help] someone think about things differently, because that's really what it is. I never had the opportunity to give insight. I was only a listener up until that point. But then when I was able to give the insight with that and they were like, oh, I never thought about it.
[00:07:31] I was like, “What did I say? I said that. I said that. Yeah, that was really good.” But I just think therapy is a wonderful thing for all people. And I don't just say that because I'm a therapist. I say that because I'm a person that goes to therapy and there is nothing like having a person who does not tell you about themselves for one whole hour a week.
[00:08:00] Dr. McBride: Amen. And I'm a believer as well, and I love that story that you had this firsthand experience of being an empath and listening and observing. I think I agree with you that therapy is a wonderful way of having that space and time to download our thoughts, feelings, and talk about our behaviors and relationships.
[00:08:26] I do think, however, there is a difference between therapy that is simply chewing over the day's news and the data dump in therapy that is, I think, what you do, which is helping people affect change. And having the courage and tolerance for distress, they need to affect change. And I actually, I just talked to a patient today who's been in therapy for about a year, and you and I can agree that it takes sometimes years to make changes, but I asked her because she isn't feeling better vis-a-vis some things in her life.
[00:09:07] Do you think it's possible you're not bringing the whole story to your therapist? I think we all have parts of our lives that are so vulnerable that it's hard to even bring up to ourselves, not to mention to another person. And I said maybe it's like at the museum when you kind of rope off a part of your story that you're not accessing.
[00:09:29] And I don't know if you have thoughts about that, but I'm guessing you do. But I just think that I said to her, I would, I would love to challenge you to bring more out and maybe think about other issues in the relationship with your therapist that make it harder to do that. I push people.
[00:09:46] Nedra: Yeah. I'm excited for the people that I work with who are brave enough to be deeply honest. It requires some honesty to admit the things that don't make you look good. Everybody loves to tell the story of, I can't believe they did this to me, or Can you believe this person did blank? Not many people acknowledge I did this to this person and it wasn't very nice.
[00:10:15] I've recently thought of a story only because something happened to a person in my life where they had this friendship sort of situation where someone did not honor a commitment. And I said, oh, I remember one time, I think I was like 20. I did not honor a commitment and I ghosted that friend after because I could not address it.
[00:10:42] And they were like, “Really?” I was like, yes. I'm like, put it in my obituary that I apologize to this person today.
[00:10:52] Dr. McBride: Yes.
[00:10:54] Nedra: I even tried to Google them. I was like, “let me email them.” I'm like,
[00:10:58] Dr. McBride: That's hilarious.
[00:10:59] Nedra: I've done one bad thing in life. That's it. No, probably tons, but this is the one that is sticking out. And they were really shocked. They were like, “I can't believe you did that.” I'm like, “I didn't want to do it.” I didn't know how to end the relationship. And in my immaturity, I did it in a very explosive and probably damaging to the person way is not something I'm proud of. I would never do anything like that today, but I did do that and it does not make me look good.
[00:11:32] Dr. McBride: Well, I think it makes you human, Nedra, and it's like just the process of being human and sort of sharpening our tools for managing relationships and honoring our needs and honoring the other person's needs. I'd love to talk about acceptance for a minute. So you wrote on your Instagram recently, and I screenshot it—a little secret from a therapist.
[00:11:56] “In relationships, we often think the other person is the problem. If they changed this or that, your life would be better. Sometimes the problem is you not accepting that you can't change the other person and you have to change for the situation to improve.” And then you wrote in bold repeat after me, and this is where I thought, oh my gosh, this is so good.
[00:12:19] “I am not in control of others. I am in control of myself.” One of the things I was telling a patient today or not telling, one of one of the things I was talking to a patient of mine today who is a middle-aged woman, mother of three, and a born sensitive empathic pleaser who is coming in not feeling well emotionally and physically asking me if she should be on more Zoloft when we drill down to the issue is really that she's not erecting appropriate boundaries with her family. They have expected her to jump through hoops in every department of her life to please and satiate their thirst for whatever she's offering, and as a result, she's feeling exhausted and burnt out and resentful. So there's no amount of Zoloft that can help her tolerate that. What I talked to her about is I said, first of all, buy Nedra Tawwab’s book, And she said, which one?
[00:13:20] I said, well buy both because they're both really good. And then I said, let's think about retraining your family and rehonoring your needs in the relationships. And, and I'm gonna make this a question, accepting that painful acceptance of realizing your parents and your siblings may not change. They may not want to ask less of you, but you can hold the line.
[00:13:47] Nedra: You can do less. They can ask whatever they want to, and you can do less. Take it from a person who gets countless amount of dms,
[00:13:58] Dr. McBride: Oh my gosh. I'm sure.
[00:14:00] Nedra: All so many requests. I meant, here's my question for you. Here's this thing I need. I can't respond to all those things and show up in my life. It's not possible in a healthy way. I'm not gonna say it's impossible. It's not possible in a healthy way. It's not possible to fulfill many commitments the way that we do sometimes in a healthy way. We do it while other things are suffering. Can you imagine that here it is, you haven't even had a glass of water and you're doing all these things for other people. You haven't even had your yearly checkup and you're doing all these other things for people. You are last on your list. Your health is suffering. You have things that you need that aren't being honored, and your concern is, “oh my gosh, they’re gonna be so upset at me.” You may not be here at the rate you're going.
[00:15:00] They're gonna be upset at a ghost. They're not gonna be upset at you because you're not gonna be here, you're not gonna be, well, you're not gonna be able to keep this up long term. So stop it now. Stop it before it gets to a point where you know, the migraine is actually really a issue now. It's not, it's no longer just, oh, I'm having the occasional headache.
[00:15:22] You've worked yourself into hypertension, now you have hypertension. Because you're doing these things at this high capacity that is not sustainable. And I think about people who have to take things to be able to get through the day. So there are some people who will take a painkiller every day just to get through the day.
[00:15:43] I have a headache every single day. I have a whatever. Every single day I've watched Dr. Pimple Popper. Oh my gosh. And those people, they'll have this growth on them for 20 years, and I often think, what have you been doing that long that you couldn't get yourself to the doctor? 20 years? That looks like something that should have been removed after two months. But there's all of these other places, all of these other things that we have to do other than taking care of ourselves, which is the most important thing in life for us to show up in these other spaces.
[00:16:24] Dr. McBride: Why do you think it's so hard for women in particular? I think it's true for men as well. Why do you think it's so hard for humans to center their own needs? I mean, what are the themes you see in your practice that people come up with?
[00:16:41] Nedra: The voices of other people dictate what we choose to do on our lives. People are going to think it's selfish. I'm not being a good this. That's not kind, that's not loving. I think about the statistic that married women die sooner than married men. Not sooner, but they don't live as long as unmarried women.
[00:17:07] So unmarried women because they have less responsibilities and probably less stress. They live longer than married women. And I see that manifested in my family where both of my grandfathers outlived my grandmother's, and it's just, I remember my grandmothers being such hardworking women who didn't even, you know, when it was time to sit down to eat, they weren't even hungry anymore because they'd done so many. It was like, I don't even have an appetite.
[00:17:38] I've done all this cooking. I've been cleaning, I've been folding, I've been doing all this stuff. I don't even have space to eat anymore. I just need to sit down. And I remember being a little girl, grandma, how can I help you? Can I sweep the kitchen? Can I… because you see it and it's like, Oh my gosh, the modeling.
[00:17:56] And so we think that's womanhood. We think that's love. We think that's being compassionate and what it is, is being overworked. It's being run dry. It's being, I don't wanna say taken advantage of, because if you don't know that you shouldn't be doing it, you're not being taken advantage of.
[00:18:17] But it's certainly being disregarded in a way that other people don't even have to consider. It is not healthy for us. It's not healthy for women or men. You know, if a man is in that situation, I don't want you to work that hard, especially when you're not the only person. You're not the only person in the household, and so for any of us working alone, it is a lot and we have to rely on other people. We have to have some communal support. We cannot be the only person doing the things.
[00:18:55] Dr. McBride: What do you think your grandmothers would say about your sort of exquisite ability to have healthy boundaries in your own life. I ask because one of the common things we say to each other, myself included, when we try to have healthier boundaries, like saying no is saying yes to something else… is you're worried about what other people will say or think, particularly if they are used to getting a certain behavior from you.
[00:19:27] Did you ever get any pushback from your grandmothers when they were alive, or did, would they be proud of you that you are paving the way towards improved self-awareness and care? What would that be like in your family?
[00:19:39] Nedra: I think I'm an evolution of myself. When I see video footage or hear stories about me as a kid, I've always been outspoken. I am the youngest grandchild, so I got a lot of passes, the almost get in trouble type person like, you're gonna get in trouble. But I never quite got in trouble because I was little.
[00:20:02] It was like, “okay, whatever grandma, you'll forget.” Right? I see. You know, videos of myself and I'm like, wow. I said that. You know, I remember as a kid often being told, you can't say that to your mom, or, why are you talking like that? Your mouth is smart. But I would just challenge things. I would ask questions if I knew something was maybe wrong. If my mother said, you know, you have to eat liver, it's healthy for you. And I'm like, why? It's so nasty. How is it healthy? So like what part of the vegetable is a liver?
[00:20:38] Lucy: So you were always a curious and sort of self advocating person, like you didn't just take things for what they were. It sounds like you always wanted to know why.
[00:20:49] Nedra: Yeah, I've always been curious why, what is this? How and in some relationships, not all, there are some where I've just like, be quiet, you're gonna get in trouble. But in some relationships it was certainly allowed and I'm very grateful for that, that I was allowed to, you know, have some very early boundaries and I would even set boundaries with myself to test out my discipline, I would test my discipline. I remember I stopped eating red meat in high school because I just wanted to see if I could do it. I'm just going to do it. Like, I just wanna see if I can, and I did. I just wanted to see how courageous can I be for myself?
[00:21:35] Lucy: Nedra, when you're counseling a patient about erecting healthy boundaries with family, for example, and the relationship is challenging and you're trying to give them some space and distance from their family without cutting them off. How high does that boundary need to be? I think about Hurricane Katrina. It can rain and storm and the levees can hold, but at some point the levees break. And so maybe what you're trying to do is build the levees a little higher, a little more robust, so that it can still rain and storm, but the person doesn't fall apart, the levees don't break. How do you know how high to build that moat? And how do you know when it's time to really kind of cut off a relationship? What is the appropriate height of the wall that you're building to protect yourself and still have a relationship with other people?
[00:22:34] Nedra: That's always a tough question because I think it's really based on the person. Everybody's wall is built at different levels, and there are some relationships that no matter how hard they are, some of us will not end them. So it's really about the least amount of impact. It is not about letting the relationship go.
[00:23:00] What I deem as intolerable for me may not be intolerable for you. It could be some… that's just the way that person is. Okay, well if that's how they are, how do you deal with it? If you have a family member who's always commenting on your weight, how do you just live with them, commenting on your weight and they just won't stop it, and you wanna keep this relationship with them? Sometimes those are choices that we make, but we have to recognize it is a choice. We are in this relationship because we want to be in it. I want to be in this relationship with this person, even though I don't want this, other behavior from them. I want to be in this relationship. It's important to me.
[00:23:42] Dr. McBride: Yeah, I think what you're talking about, if I may, is sort of. at the entire picture of the relationship and then accepting the parts you're willing to accept. You're right. I mean, some people would leave a spouse who is a substance abuser. That's just the line in the sand for them. Maybe they've given their spouse or partner three tries, and fourth time you're out.
[00:24:08] Other people would've left a long time ago. Other people would stay with them, even if they're actively substance using. And I think it's our job not to judge or to tell people what boundaries they should have, but rather to decide what you're willing to accept and make peace with it. And then lean into the parts of the relationship that maybe are good and joyful and where you feel like you have your needs met.
[00:24:35] I don't know, because I think when is it time to just cut someone off? When is it time to just think about maybe you have accepted things that you shouldn't have had to accept. I mean, I guess this is why you have a job, Nedra, is to go through these things with a fine tooth comb with patients.
[00:24:50] But I just think it's so important to not be black or white about relationships. I think, as you have said, life and relationships live in that gray area and we are always evolving. We are always changing, and hopefully we are always evolving for the better. I wonder what the hardest thing that someone brings to you? Is it abuse? Is it neglect? What are the hardest cases you see in your current practice?
[00:25:19] Nedra: I think many of them are hard when there's a person on the receiving end of suffering. I'd hate to say that. Well, abuse is worse than neglect…
[00:25:29] Dr. McBride: right. There's no suffering. Olympics, right?
[00:25:32] Nedra: Yes. I don't wanna weigh the two. I think that. You know, for the receiving person, not having a healthy relationship with their mother who might be, you know, in competition with them is the worst thing in their life.
[00:25:49] And that's, maybe some people will say, well, that's not as bad as being cheated on by your husband, or, I don't know… I think bad is relative. I don't wanna see anybody suffer with anything. Not a paper cut, not abuse or neglect. It's just like all the things are hurt.
[00:26:12] I don't want to weigh those things. I do want to think about how it's impacting you because what might cause another person to feel anxious is not all going to be the same. It's not, we don't have all the same anxieties or the same things that make us depressed. Everything is different in its own way, and I feel as if my job is to leave room for that and to allow people to have their own experience with their levels of dysfunction.
[00:26:45] Dr. McBride: I think that's so true not to rate our suffering and not to judge it. And I wonder what you find are the hardest or sort of the most common barriers to people building appropriate boundaries. What are the things that hold people back? Is it fear? Is it, they just haven't practiced it? Is it that this is a new concept culturally for them? What are those sticky points?
[00:27:11] Nedra: It's new and we want people to like us. If we do this thing, they may not like it. They may be disappointed. What will they do if we don't do it? If they asked us to do it, maybe we're the only person that they've asked. And so if I don't do it, who will do it for them? You know, all of these thoughts run through our heads and we don't have proof that anything is true. We just say, oh my gosh, it must be true because I'm thinking it when, you know, thinking is not the proof. Thinking is just the process. It's not the proof.
[00:27:41] Dr. McBride: You said it. I commonly talk to patients about fact checking their narrative. I completely believe that our stories live in our bodies. As you were talking about in the beginning, that when you had this experience of being in front of someone who was challenging for you, you had this panic attack.
[00:27:58] Similarly, we can have these stories that live in our bodies that aren't rooted in reality. Like the story that you are the only one who can make your parents happy or meet their needs, that you are the only person who can come to the rescue, and that if you don't do that, that they're going to not love you or not be able to be healthy. Is there a time in your life when your dad, for example, needed you and you said, “sorry, I can't do it. I could do it next week,” and then everything fell apart? Or did he call the next person? So, I think it's important that we are honest with ourselves about these stories that we bring with us through life that sometimes are actually not true.
[00:28:41] Nedra: Yeah, sometimes our stories aren't true and we've just been telling them for so long that we have started to believe them and we have this vivid recollection of this one thing happening. And we think it's. The way, and it will always be the way, but a way to really challenge the story is not to only fact check, but to talk to other people about it and see what they remember about the situation.
[00:29:05] Nedra: We are not always trusted storytellers because we're telling things from our perspective. There was this show that came on a few years ago called The Affair, and they would tell it from three sides. And it was always interesting because one person would think that they said things in this way and it was like, nope, it was said in this way.
[00:29:27] And it was just like, oh my gosh. To think that that is how life is playing out. Even someone will say to me, “why did you say that like that?” I'm like, “say it like what? I think I just said no thank you.” And they're like, “no, you said NO, thank you.” I'm like, “did I? Oh my gosh. That's not how I said it in my head, I didn't think it came out that way,?” but you know what we perceive to be happening all the time, it might not be accurate. I think the better judge of what's happening is what's happening with this person and other people. I think that's a better judge. Like if there's a person who you find to be problematic. Do other people find them to be problematic? Are they able to have healthy relationships with other people? If so, you know, you may wanna look inward and say, what? What is going on in our relationship where it's just me?
[00:30:21] Dr. McBride: I think that's true. A little humility. I had a patient many years ago who told me that she had moved house four or five times in the past eight years because of the neighbors. The neighbors here were doing this, the neighbors over here were doing this, the neighbors over here were doing this, and I thought, I wonder if it's the neighbors. Do you know what I mean? I mean, I think we need to look inward and think maybe I am responsible for some of this conflict or some of this drama. And as you said earlier, Nedra, I think that is one of the hardest things to do, is to consider ourselves flawed and to be honest about the things that we have done that potentially harm other people.
[00:30:59] Dr. McBride: And I also think it's true that we all have a story that we carry with us and then families have stories, and for some of us, as you've talked about, you know, a lot, our family of origin is a solid foundation that feeds our confidence and helps us navigate life challenges. For some others, the family of origin is a source of pain, hurt, and conflict.
[00:31:27] And I wonder if you could comment on sort of generational trauma and what that looks like and how you might counsel a patient to be sort of a cycle breaker. I don't wanna use that word too much because it feels so kind of trendy, but it fits right. It's a cycle of—I don't know how you describe it—but I would describe generational trauma as sort of a cycle of sort of hyper vigilance, a trying, a vigilance about protecting ourselves from pain that accidentally backfires. Mental health-wise, behavioral health-wise, relationship-wise, and then we learn those behaviors from our parents and then we pass it down to our kids. I wonder how you think about generational trauma, particularly in this country, particularly around race, and then how you counsel patients to be a cycle breaker, to have the courage to not carry that with them in their own body and then in their own family.
[00:32:27] Nedra: With people who are cycle breakers, I find that the most challenging thing is for them to find community because they often look for that community within the cycle. So it's like, oh my gosh, like, you know, this pattern exists in my family, but I'll go to my family where everybody has this, this pattern and say, “why aren't you guys accepting me? I'm breaking it.” And it's like they're still in the cycle. So some of the community and the support you need around this is going to be from your chosen family is going to be from you know, friends, coworkers, community support. therapy, all of these other spaces and maybe a few people in your family, but it may not be everyone.
[00:33:08] So the biggest thing with cycle breakers is helping them find community and not trying to be the therapists and their family. Often when you are the person who's made some of these shifts, it's very hard not to want the other people to come with you. It is—most of us will make it our new job to make everybody else as well as us. You know, I read Set Boundaries, Find Peace. You must read it and process everything in the same way that I do. But you'll, you'll be surprised how many people read a book and they still see things differently. They're thinking about boundaries at work. When you're thinking about boundaries with them. They're like, “wait a minute, this was about me?”
[00:33:53] We get things in different ways because we're getting what we uniquely need, and it may not be what you think I need or what cycle you think I need to break. I may break a cycle that you didn't even know I had. So it's really interesting with cycle breakers that you take really good care of yourself and you allow people to maybe access the information if they want it, but you don't make yourself accountable for their healing.
[00:34:23] Dr. McBride: I think that's so well said, and I think it's common also to see people who are cycle breakers be triggering to people in the system in which they came. In other words, the healthiest, emotionally healthiest person, the person who has erected the most appropriate boundaries or has done the most work, which again, doesn't make them morally superior, can be thought of as a threat to a system that hasn't caught up. And I think that is something that we have to acknowledge can be a thing that holds the person back from actually breaking the cycle.
[00:34:58] Nedra: Absolutely.
[00:34:59] Dr. McBride: It’s so easy to be, as you know, it's so easy to be angry, afraid, ashamed, and to perpetuate a narrative that we are not enough, that we are not worthy. It's like, why is that so easy? It's harder to say No, I'm, I wish I could, I can't, you know, sorry. With a full period, you know, we all do that. Sorry. But you know, I just really was upset about it and I really just, I didn't mean it, but you know, the, sorry, with a million explanations after it or the, I wanna talk to you about something, and it's gonna be just a few minutes and it might be kind of awkward, but let's talk about it anyway, just to be direct, be clear.
[00:35:37] And be warm and firm in the same space. I think that is not something we're born to know how to do. I just don't. I think we are, you know, we teach our kids how to read and write and we prep them for college and we worry about them driving and in relationships and we haven't taught them about healthy boundaries. And this is why your work is so important Nedra, I just think you have like, Captured this moment in such a beautiful way. And I don't mean that in a hyperbolic, I'm fawning on you because I want to be on your podcast, which I do. I'm just being honest because I just think that we need to reconceptualize health as more than the absence of disease.
[00:36:15] It has to be about these kinds of concepts, which isn't selfish, it's not egocentric, it is simply to name our humanity. And I think it's just a wonderful thing you're doing.
[00:36:29] Nedra: I think it's a wonderful thing that you're doing, having people look at health in this broader sense, and not just coming in for sick visits, but also maintaining some level of wellness and of total being.
[00:36:42] Dr. McBride: I thank you for that. My patients know that I'm interested in mental health, such that one of my sweet patients whose dad had died the year before. And we had talked through her grief and she was doing some therapy. She was in college at the time. She came in for her annual checkup a year later, and she was wearing this necklace that had a little carrot on it.
[00:37:01] And she said, what is the carrot about? And she looks at me and she goes, Dr. McBride, it's just a carrot. Like she just didn't, it didn't have any sort of meaning or metaphor. I'm gonna let you go Nedra, but I just wanna close with your great quote. End the struggle. Speak up for what you need and experience the freedom of being truly yourself.
[00:37:27] Nedra Glover Tawwab, thank you for your work. Thank you for your honesty. Thank you for your clarity in speaking directly to audiences, and thank you for being you.
[00:37:40] Nedra: You're welcome. Thank you very much. Have a great day.
[00:37:43] Dr. McBride: Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a [email protected].
[00:38:05] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician beyond. The prescription is produced at Podville Media in Washington, DC.
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Pain is an inevitable part of life. But did you know that pain is not just about body parts?
Dr. Rachel Zoffness is an Assistant Clinical Professor at UCSF and leading global pain expert who is revolutionizing the way we conceptualize pain. She explains that hurt (pain) and harm (damage) are not the same—and that pain is never purely biological. Similarly, treating pain is never just about pills. It’s about addressing the social-emotional context around it.
On this episode, Dr. Zoffness sits down with Dr. McBride to discuss how thoughts and feelings inform the experience of pain. And how treating pain must include treating the brain.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
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Transcript of the podcast is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.
[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at
and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go Beyond the Prescription.
[00:01:02] I'm delighted to welcome to the podcast my friend Rachel Zoffness. Dr. Zoffness is a PhD, pain psychologist, assistant clinical professor at UCSF, and an author of a new book called The Pain Management Workbook. She believes like I do, that our bodies and minds are inseparable and that we need to think about pain in a much more nuanced way.
[00:01:25] In other words, when I was trained in medical school, we thought pain was about the body part and that pills were the solution. When actually, as doctors, we describe pain as a biopsychosocial phenomenon. Rachel, I am so happy you're here today. Thank you for joining me.
[00:01:42] Dr. Zoffness: Thank you for inviting me on, Dr. McBride.
[00:01:45] Dr. McBride: What I love about you is that we agree that mental and physical health are inseparable. When I was training in medical school in the 1990s and early 2000s, we were taught that pain was about the body part itself, and that we used medicines to treat pain. We used Tylenol, Advil, opiates, and we were taught to get ahead of the pain and to get people more opiates than we thought they might need because it was cruel to deprive people of pain meds, which of course it is in many ways.
[00:02:16] But we now know just how addicting these medications are, and we also know that pain is about more than the limb that is hurting. So could you describe for me how you talk about pain, this bio psychosocial model? Because it's a big word and I'd love to break it down.
[00:02:34] Dr. Zoffness: Yeah, it's sort of frustrating for people who have been living with pain and also for healthcare providers who treat pain because medicine, as you know, has been rooted in this antiquated, dinosaur era biomedical model, which teaches people that everything to do with pain is just anatomy and physiology.
[00:02:54] But neuroscience has known for many decades that that's not actually true when it comes to pain. And one of the reasons we know this is because of this syndrome called phantom limb pain. And phantom limb pain is when someone loses a limb and arm or a leg, and they continue to have terrible pain in the missing body part.
[00:03:14] Now, if you can have terrible leg pain in a leg that is no longer attached to your body, that tells us pretty definitively that pain does not just live in your leg, and it does not just live in your back. And what science says is that, of course the body is involved in pain production, but ultimately pain is constructed by the brain.
[00:03:38] And the reason that's so profound, at least for me as someone who treats pain and has lived with pain as many of us have, and all of us will because everybody, everybody is gonna have pain at some point, is that there's lots of parts of the central nervous system that process pain. It's not just there's one pain center, and that's how that goes.
[00:03:56] There's lots of parts of the brain that contribute to the pain experience including the brain's emotion centers contribute to the pain experience, and what that means is how you're feeling emotionally in any given moment, whether you're stressed or anxious or depressed affects intimately the pain that you feel.
[00:04:15] So we know from neuroscience that pain messages are amplified during periods of anxiety or during a global pandemic. That's not gonna surprise anybody, and we all know this. We all know that our bodies feel worse during times of duress. So it's really not that shocking. And we also know that, say if you stub your toe at work on the day you get fired, that exact injury feels completely different than if you stub your toe on a day at the beach when you're hanging out with your friends in the sun. So context matters, emotions matter, thoughts matter. Everything matters to the brain when it's deciding whether or not to make pain and how much, and that's always true.
[00:04:54] Dr. McBride That's a great example and the phantom limb pain is, is, I'd love to talk more about the phantom limb pain because I mean there couldn't be a better example of the construct that pain is—not to say it's not real— it's to say that it's more than just about the limb. So take that example for a second. How do you treat someone who has phantom limb pain? If it's not about the limb?
[00:05:18] Dr. Zoffness: So there is this frustrating thing that happens in medicine where people with chronic pain are often told it's all in their head. Especially if there's no known etiology for the pain. If you've had a lot of scans and tests and you know, people just aren't sure, the doctors are like, we don't know.
[00:05:31] We can't find a thing. So people get told often that pain is all in their head, and that is not what I'm saying. So I want to be very clear. Pain is never all in your head. If you have pain, your pain is real. The important thing to know about pain is that it's the brain in conjunction with the body always working together.
[00:05:47] The interesting thing about phantom limb pain, again, we've said you can have pain in a leg that's no longer attached to your body. And we've said that's because your brain is implicated in the processing of pain in your brain. You have what's called homunculus, and a homunculus is literally a map of your entire body that lives in your brain.
[00:06:06] So if I said to you, Lucy, without doing anything or moving, sense into your foot, can you feel your foot on the ground? Notice if your foot is warm or cold. Can you feel if your foot is moving or… you can do that. And the reason you can do that is because you have a map of your whole body that lives in your brain, your homunculus.
[00:06:23] So sometimes if you lose a limb, you've lost the limb, but you haven't lost the leg part in your brain map. So with mirror therapy, what we do is. We hold a mirror up to people who have phantom limb pain and they go through a series of activities and structured exercises to help the brain become unconfused and realize that pain, which is your body's danger detection system, doesn't need to send you any more danger or warning systems because the damage has already occurred and there's no warning signals that need to continue. So that's one of the treatments for phantom pain.
[00:06:58] Dr. McBride: It's such a great example and I love the way you described it because I think for a lot of people, doctors included, we have a hard time wrapping our arms around this concept of suffering you can't measure or you can't see it, but everybody who's listening right now can think about their toe or their foot and know that you're directing your attention to it, and there's a reason for it's in our brain. So that is great. That's a beautiful way of opening this conversation about pain being more than just physiological.
[00:07:31] Dr. Zoffness: Exactly right.
[00:07:32] Dr. McBride: Talk to me about—breakdown biopsychosocial, because when someone hears pain is biopsychosocial they may think, oh wow, it's more complicated than I thought, but they don't necessarily know what that means. So what is it?
[00:07:45] Dr. Zoffness: Right. So I happen to really love big words, and this big word in particular has helped me make sense of a lot of different things, not just pain, because it turns out anxiety is biopsychosocial, and depression is biopsychosocial and diabetes. So I'm going say what this word means. So biopsychosocial, what we know now about pain, is that it is never a purely biological thing. It's never just to do with your bad knee or your aching back. Never. It is more complicated than that. Of course it is. And so with this word, biopsychosocial means, and we know that that's what pain is. It means that there, of course, are biological components or triggers for pain contributors
[00:08:25] So the bio components of pain are genetics and tissue damage and system dysfunction and inflammation, and things like diet and sleep and exercise. Those all are biological contributors to pain. They're very, very, very important. However, what we know about pain is that there's other things that contribute to your experience too, and they're just as important.
[00:08:48] It's not that they're less important. So in the psych, we have bio, we have psych, and we have social or sociological. And the psych domain of pain has so much stigma around that. And I am a pain psychologist, and let me just tell you all day long, all I do is try and explode the stigma around these quote unquote psychological contributors to pain.
[00:09:08] So I want to very clearly say, When you say that pain has psychological components, that's not, again, that it's all in your head. What it means is neuroscience shows that emotions intimately affect the pain we feel, and that negative emotions are going to amplify pain volume and positive emotions and feelings of calm and relaxation are going lower pain volume, turn pain volume down so that lives in that psych bubble.
[00:09:35] Also, in that psych bubble, we know that thoughts and beliefs intimately change the pain we feel. This is supported by many decades of science, for example. We've all heard of the placebo effect. The placebo effect means, Lucy, I'm gonna give you a sugar pill. I'm going to tell you as a pain doctor that this is gonna lower your pain volume, and low and behold, you actually feel better.
[00:09:59] That happens a lot of the time, and the reason that happens is not that the placebo pill is nothing, rather the placebo means you change your beliefs and your brain understands that these danger messages are not needed anymore. So your pain volume is lowered. Beliefs and thoughts change the pain you feel.
[00:10:19] That doesn't mean you can think your way out of pain. It's more complicated than that. But thoughts and beliefs matter. We also have in this bubble coping behaviors. What do I mean by that? People with pain often, understandably believe that they need to stay home, stay inside, not move, not go outside, stop going to work, stop their activities, stop moving.
[00:10:40] Reasonable. However, what science shows is that that ultimately is also going to amplify pain volume and that to treat chronic pain, we have to get out of bed and back to life very slowly and in a structured way, and I'm not telling people to go outside and do things, but behaviors, how we act, how we handle our pain also changes the pain experience.
[00:11:01] Then I said, we have this third domain of pain. It's the social or the sociological domain of pain and what science says is that social factors matter all the time. When it comes to pain and health, humans are social animals. We know that the worst punishment you can give a human being is not Thanksgiving traffic, and it's not your in-laws, it's actually solitary confinement. And what happens when we are lonely and isolated and alone, which happened during the pandemic to a lot of people, our brain amplifies pain volume because a lot of brain chemicals change. So in the presence of others, our brains produce all these chemicals that literally make us feel good.
[00:11:42] Dopamine, serotonin, oxytocin, and endorphins. Endorphins are our brains’ natural painkillers. They are our endogenous opioids. So in the presence of other people, brains produce painkillers. There's other sociological factors that matter also. It's community, it's context, it's environment, it's even race and race and ethnicity, and even racism.
[00:12:07] It's poverty and it's access to care, it's trauma. There's so many, so many things that live in this sociological domain, so, All of it together contributes to the thing, this experience that we call pain. And what's happened in medicine is that we’ve distilled it down to just the biological, the bio bubble. And what that means is that what we've been doing in medicine is missing two thirds of the pain problem. And part of the reason I do things like this and come on podcasts, is to try and change the way we're thinking about pain so that we can change the way we treat pain.
[00:12:41] Dr. McBride: It is so important, Rachel, because as you just said, we have reduced the patient to a set of lab tests, a set of complaints, and because doctors don't have time and they aren't trained—we are not trained in pain management like we should be—People who are in chronic pain are often thought to be nuisances, thought to be malingering or thought to be making it up, because we don't have sophisticated ways of treating pain and because it takes time to access the 360 degree version of the person we prescribe pills. Now, I love Advil for a headache. I love Tylenol when I have a fever. But I think what you're saying is that we need to look at the whole person. We need to look at their emotional health, their mental health, their physical health, their story, and address the various complex parts of this person because they're integrated and they show up in pain.
[00:13:40] Dr. Zoffness: That's exactly right.
[00:13:41] Dr. McBride: Can you give me an example, Rachel, of a patient who had intractable pain, who was treated inappropriately by the medical establishment and then got better with this model.
[00:13:52] Dr. Zoffness: It's really interesting. I'm in private practice and I see people with chronic pain and I happen to love working with teenagers in particular. They're sort of forgotten in medicine, especially in the world of pain. We have pediatric pain and we have a lot of adult pain and older adult pain work. It's not being done right in my humble opinion. But we do have a lot of attention and money being thrown at it. And then we have teenagers who are sort of in this messy middle, like they're not quite children, they're not quite adults, but meanwhile, all they want is an adult who will talk to them as if they're an adult.
[00:14:21] They want that sort of respect. They don't wanna be talked down to like a child anymore. And teenage pain is very confusing for a lot of doctors, in part because they fall into this messy middle category and people aren't sure, do we involve parents, do we not? So one of the patients I was thinking of who came through my program was a 16 year old who had been diagnosed with chronic daily migraine that was so debilitating that he couldn't get out of bed. He also had been diagnosed with abdominal migraine, so chronic stomach aches, stomach pain, and he also had diffuse, amplified body pain of no known etiology. So no one really knew where it was coming from or what was going on.
[00:15:00] And when I met him, He had been in bed for about four years and had missed four years of school. And when he showed up in my office, I want to describe him to you because I will never forget this as long as I live. He came into my office, he had long unwashed hair and he was pasty and pale, and he was heavy because he hadn't been moving his body and hadn't been exercising, had truly been bedridden.
[00:15:25] And he started rocking himself back and forth on my couch with the pain. And I remember thinking like, he's been through Stanford, he's been through UCSF. Who am I to do that? I almost called his neurologist to say I can't do it. Thank God I didn't. But it's just funny. I think as healthcare providers, we all have a little bit of this imposter syndrome—can I do it? And so when I take a history, I don't just ask about the pain and when it started, I want to know everything. Because as we all know now, there's always a pain recipe. There's always bio ingredients and there's always emotional ingredients. There's always contextual and environmental ingredients.
[00:16:03] There's family ingredients, there's trauma. There's coping behaviors—all of that is baked into a pain recipe. So I asked him about his emotional health. He had been paralyzed with social anxiety for most of his life, untreated. He was depressed. He was suicidal, which is not that surprising actually, when you're 16, you have no life, You've been in bed for four years. He had been on 40 medications. He had seen 14 specialists and experts. It's understandable to me that a 16 year old might feel hopeless and helpless and in fact, that's true of a lot of patients who come to me. I am the last stop on the train. Nobody wants to see a psychologist for pain.
[00:16:42] Nobody, and I understand why I also would not want to. So, I realized pretty quickly that there were a lot of parts of his pain recipe that were not being treated. So when we started the program, we did get his parents involved for a number of different reasons, and one of those reasons was that he needed support doing some things to help his social anxiety go down, help his mood improve and help us pain improve, because all of those things are intimately connected all of the time.
[00:17:10] My mantra is that the brain and body are connected 100% of the time. They're never not. Ever. So of course your emotional health affects your physical health. So one of the things we needed him to do in order to help his pain and his mood was start moving his body. And you can't ask someone who's been in intractable pain for four years to go outside and hang out with friends.
[00:17:30] That's not how that goes. So week one, he went out onto his porch and stood in the sun for 10 minutes a day, every day for a week. Week two, he walked the corner mailbox and his mom would give him mail to put in the mailbox. Week three he would walk around the block and he would stop at the corner store and order tea or coffee or whatever, just to have human interaction. And by the way, this was paralyzingly difficult for him and part of our pacing plan, because that's what this was and I'm happy to explain what that is. You go slowly to increase activity, whether it's social activity or physical activity. It was really hard for him. And he would have pain flares. Absolutely.
[00:18:11] And we built that into the treatment strategy. So he would take breaks, as many as he needed. He could take the whole day to get the walk around the block and the stopping for coffee done. Week four, he walked his dog to the dog park and had a conversation with someone. Week five, he mixed in a little bit of jogging and texted a few friends. So as you can see, there was a gradual increase in activity, both social and physical. It was targeting his anxiety, it was targeting his depression. We know that behavioral activation is very critical for depression. We know that social exposure is very critical for treating social anxiety and slowly, slowly, slowly, his mood improved.
[00:18:49] Anxiety started receding, pain volumes started going down. At some point, his neurologist called me and said, “What magic purple pill are you giving this kid?” And I sort of had to say—suppressing my frustration—yeah, that's the whole point. It's not a magic purple pill. And he gradually got back to school and he rejoined his soccer team and he started playing soccer again and his pain went away and he went off to college and became captain of his swim team or whatever. And listen, just to say, this is a kid who's still, he's an adult now who still has migraine, but his migraines do not debilitate him and they will never again dominate his life. And he will never again be in bed for four years because now he knows he has to look at his whole pain recipe. He can't just take medications forever. And I am not. Saying that medications are not helpful, thank God for medications. What I am saying is that it's a bigger picture and humans are more than just a body part.
[00:19:50] Dr. McBride: Amen. Hallelujah. I mean, this applies to really any suffering I think that you cannot measure in a blood test whether it's depression, anxiety, PTSD, chronic fatigue. Patients who don't fit in the mold or, or who don't have a diagnosis that we can see on paper get so easily dismissed by the medical establishment and also get, there's self-stigma, right? When people don't have a, when there's nothing you can hang your hat on from a lab abnormality, it can eat away at your sense of self. And then what's worse is when doctors are not counting your story and you don't then have access to your whole interior world, which is of course essential to how we function in the world every single day.
[00:20:44] And you're right—there's no partition between head and body. It's not like there's a neck down kind of version of humankind. What is your advice to people who are listening who have chronic pain, say from hip injury, a herniated disc, migraines who are thinking to themselves, Huh? I have some imitrex for my migraines. I have some Advil for my back pain. I know how to stretch and move. My life is stressful, but I'm managing it. What else should I be doing?
[00:21:17] Dr. Zoffness: So I'm one of these people who believes that appropriate pain care should be affordable and accessible to everybody. So I published a book during the pandemic called the Pain Management Workbook, and in there is everything to do with pain science. Very digestible. It's like neuroscience that anyone can read, and it also has a ton of strategies in there.
[00:21:39] And I think the most important thing, if you're living with pain or if you treat pain and you're not sure what to do next, is to figure out how to put together a pain recipe. And that's in the book, the Pain Management Workbook. And I'm gonna say what that is and what it means. Every single person has a pain recipe, everyone. So for me, my pain recipe, for example, is sitting for too many hours without getting up and moving, not exercising, eating poorly, not taking care of my body, poor sleep, fights with my family or my partner or whatever. A lot of stress at work. I know that if it's a high stress day, I probably will not have a good pain day.
[00:22:22] And also my level, managing my level of stress and anxiety, so whether I'm actually actively incorporating self-care, like am I going for walks? Am I going outside in the sun? Am I making sure that I'm scheduling time to be in nature or go to pleasurable activities? So that's my pain recipe.
[00:22:42] And as you can see in that pain recipe, there are bio components, there are cognitive and emotional and behavioral components, and there's social components always. And so when you put together a pain recipe, the cool thing about it is, there's always a high pain recipe. Like I like to ask people like, you know, do you like to cook or bake?
[00:23:00] Because I do not. But as you know, if you like to cook or bake, there's always a recipe that will get you to the end point that you're seeking. And the same is true for pain. Like just as there's a recipe for brownies, there's a recipe for pain. And so I just gave you my high pain recipe. The cool thing about a high pain recipe is that a low pain recipe is the exact opposite. A little bit more nuanced than that, but there's always this high pain recipe, low pain recipe sort of thing. So for me, sitting for too many hours without taking a break is part of my high pain recipe, and the reason that's great valuable information is because I know that to manage my pain, I need to set my alarm every hour and go for a walk outside, even if it's literally two minutes, five minutes, or my next phone call, I take it on a walk around the block, whatever.
[00:23:49] Whatever I have to do to structure in these things that I need to get to a low paying recipe. That's what I do like scheduling pleasurable activities and walks in nature on the weekend and making sure to see friends and making sure to put boundaries around toxic relationships and not spend time with certain people, because guess what? You're allowed to do that. So whatever ingredients are in your high pain recipe, figuring out that recipe is the way to lower pain volume. So that's one of the strategies in the pain management book.
[00:24:16] Dr. McBride: I love it. I think at the root there, Rachel is, is a self-awareness. Giving ourselves permission to look inside and to think about, as I say, our stories and how they live in our bodies. To take time to look at the narratives inside, some of which are rooted in fact, and some of which are not rooted in reality.
[00:24:34] For example, the patient who says, I've been in bed for four years. I am a broken person. I'm an identified patient in the family, I'm a problem. You know, if you, if you organize your thoughts, feelings, and behaviors around a narrative isn't fully fact-based, then that's only gonna exacerbate the very problems you have.
[00:24:56] So, making sure, obviously someone who is suffering is entitled to feel like they are a patient or a challenge. But if we can look inside and access our stories and then ideally rewrite some of those narratives like I can and I will and I'm able, I mean the agency there. I think a little bit of what you're talking about is sort of making your own recipe, making your own kit so you don't feel so helpless and a victim of yourself.
[00:25:28] Dr. Zoffness: And I think that goes back to this thing where there's cognitive components to pain and beliefs matter a lot. This particular patient I was talking about believed that there was no hope for him and understandably so. And the first thing I told him when he came to my office was that I was going to help him. And of course, I didn't know that for sure, but I knew for sure that he needed to believe that. So I said, I can help you and, and I knew that he needed to believe in me for any of this to even work.
[00:25:53] Dr. McBride: The other thing is the trust you're describing. I mean, for me to help someone—I'm sure it's the same for you as a clinician—to help someone who has an intractable problem, whether it's obesity or PTSD, heart disease, to feel like they have hope and possibility. They have to really, really trust the messenger and the guide because if you feel hopeless, if you feel like there's nothing out there for me and you've been treated like a bag of organs and not a person, that alone is a barrier to care. And so just aligning with the patient and leading with empathy and curiosity in my mind opens the door to that partnership, which sounds almost corny and hokey, but there's an incredible therapeutic benefit to the patient when you can align… And it's like, believe the patient, they are not making this up.
[00:26:49] No one wants to make up a story of, I'm in so much pain, or I have experienced something that is unique to me, no one's ever experienced and I'm alone. No one wants to feel that way. And so just giving people permission to be human and then by a doctor or PhD, Rachel's Zoffness, that's a meaningful intervention.
[00:27:10] Dr. Zoffness: Yeah. I was also thinking about what you were saying before about how, and it's so true, how chronic pain patients are such a challenging population for doctors to treat, and there's a bunch of papers actually that have come out on this that show that one of the reasons for this is that there's a lack of pain education in medical school, and there's this crazy statistic that sort of blows my mind, which is that 96% of medical schools in the United States and Canada have zero dedicated compulsory pain education. And all these subsequent papers that came out where physicians were interviewed, like, how comfortable do you feel treating pain? And it's what you were saying before, there's this lack of comfort, understandably.
[00:27:47] How are physicians supposed to feel, or any of us as clinicians supposed to feel comfortable treating a thing that we haven't truly been taught about in part because it's not really well understood. It happens to be well understood, but it's not really, the education is so poor. Like as a patient. Do you ever get taught about pain if it's not really being taught in medical school, it's not being taught to, to the lay public. So how do we treat a thing unless we really understand it?
[00:28:14] Dr. McBride: Exactly, and then doctors don't have time. It's not the doctor's fault, it's the system's fault. We don't have time to elicit the whole story and the whole landscape of that person's interior world, and then we have to know what to do with it. And that takes time. And that's just not what modern medicine is designed to do right now.
[00:28:32] Dr. Zoffness: No it's not. It's a profit driven healthcare system.
[00:28:34] Dr. McBride: It's awful. What do you see as the relationship between chronic pain and addiction?
[00:28:41] Dr. Zoffness: So it's interesting. I started teaching at Stanford a couple of years ago and I'm teaching the Addiction Medicine Fellows, and I remember when I first went down this rabbit hole in pain science, realizing that addiction, medicine and chronic pain have started to become synonymous, and I am a nerd, and the way I make sense of the world is by reading everything.
[00:29:05] So I started reading every single paper I could find. Here's a heartbreaking statistic. 80% of people in America who have become addicted to heroin started out as pain patients. There's this disconnect, I think until recently that we, and there's also a lot of blame, like people with addiction are blamed for their addiction. But 80% started out as pain patients. That means they went to their doctor, this person they trusted and they were like, help me. I have pain. And the doctor, totally, understandably because doctors were lied to for forever [and told that this] medicine is the thing you need to give. It's the treatment for pain. They gave this medication that hijacks the brain and hijacks your central nervous system.
[00:29:46] Dr. McBride: You're talking about narcotics and opiates.
[00:29:49] Dr. Zoffness: Correct, oh, did I not say that? Sorry. Yeah.
[00:29:51] Dr. McBride: No, but that's, I just wanted to tell you because I mean, that's what we were taught in medical school.
[00:29:54] Dr. Zoffness:Yeah. Oh, no, no, absolutely.
[00:29:56] Dr. McBride: That's what we were taught. Get ahead of the pain opiates, Oxy five, 10 milligrams Q4 to six hours, more than you think they need.
[00:30:04] Dr. Zoffness: Right, of course. And, and that's because there was great marketing. Everyone who has seen dope sick knows this now. Yeah. And there's a book called Drug Dealer MD by Anna Lemke that all of this has just been really blown open over the last couple of years. And of course now pharma is paying a 26 billion payout in reparations, but in my mind, that is absolutely not enough.
[00:30:28] The number of lives lost and the way that pain medicine has been completely hijacked is pretty gnarly. And I also want to be clear to say I am not anti-opioid. Thank God for opioids post dental surgery. If that's something that your body can tolerate, you don't have a history of addiction, like I am not anti-opioid, But the issue for me is the way we've framed pain as a biomedical problem that requires a purely biomedical solution. And we know that that's not true, and we know that that's actually wrong. And we also have known for a very long time that opioids can be very dangerous for people. So the fact that that's sort of become the de facto treatment, especially for chronic pain, is so heartbreaking.
[00:31:08] Rachel: I treat so many patients who have been in pain for a really long time and now they have two issues. You asked, like with a relationship, there are all these dual diagnosis clinics now around America where the dual diagnoses are chronic pain and opioid addiction. Like what are we doing to people with pain? It's so unacceptable.
[00:31:28] Dr. McBride: It's completely unacceptable. And then when you think about the mental health world and the false dichotomies there—I know you talk about your frustration and anger about the way. People are treated in the current medical industrial complex. My particular cross to bear is the way we talk about mental health, which is as if mental health calmness, serenity, and the ability to be happy when mental health is really the ability to have an appropriate emotional response to the setting and to have agency and tools to manage the inevitable potholes on the road of life.
[00:32:15] And then we talk about the mentally ill, which as if there's some kind of distinctive line in the sand where you go from mentally healthy to one click over, oh, mentally ill broken person, totally healthy person over here. So just like you do with your own patients, when I'm talking to my patients about their emotional health because it's relevant to their physical health, surprise, surprise, I don't say, are you anxious or, are you depressed? I say, okay, given that everyone has anxiety, where are you on the continuum of anxiety and what are you using to manage the anxiety? Where are you on the continuum of mood given that you're located somewhere on the mood continuum? What's your depression recipe? What, I don't say that but what is the thing that, what brings your mood down? And then what brings it up? And if it's recreational drugs, then maybe we should think about an alternative plan. If it's nature and being with your loved ones, maybe we need to lean into that avenue. And if your mood is pulled down by a toxic relationship, maybe we need to put a fence around it. I believe in Prozac. I believe in Zoloft. I believe in psycho-pharmacology. I also believe in treating the person and not just the pathology.
[00:33:34] Dr. Zoffness: So you said it exactly the way I would say it. And I do teach about a depression recipe. And of course there is one. During the pandemic, calls to suicide hotlines went up 8000% in some parts of our country. Now, was everyone mentally ill during the pandemic or was there an external situational trigger that made us all anxious and fearful about our loved ones or whatever?
[00:33:59] However you responded to that thing or made you feel depressed because you couldn't do all the things you wanted to do. You couldn't go to work, you couldn't go to the movies, you couldn't go to restaurants. You couldn't see your grandparents in the hospital. Of course there's a depression recipe. And depression again is biopsychosocial also always, all the time for everyone. It's not just a chemical imbalance. And by the way, a paper came out recently by Joanna Moncrieff showing that, we've all known this for a long time also, but there's no such thing as a chemical imbalance. That is an effing lie. That is a lie. If you look at all the brains of people who are depressed and not depressed, there actually is no evidence to support that people who are depressed have less serotonin than people who are not depressed.
[00:34:40] Actually, that has no evidence and no traction in medicine. So the one issue with that is, if you believe the lie you've been sold by big pharma, that depression is a biological problem that requires a biological solution, All you'll ever do is take a pill, and it's the same as true with pain, but depression is just as bio psychosocial as pain is.
[00:35:02] Dr. McBride: That is exactly right. It is not true that depression or anxiety or PTSD is a result of a chemical imbalance. That is a narrative that has been pushed out for whatever reason. And, and as a result, we end up treating patients with pills and pills alone, not uniformly. I wanna make it clear though, that's not to say that Zoloft Prozac, all these SSRIs cannot and do not help people with depression, anxiety, PTSD, and that they are appropriate for some people in the context of the biopsy psychosocial model. In other words, when that paper came out, which illustrated what we've known for a long time, it just needed to be said again, that chemical imbalance is not accurate. Patients of mine were calling and saying, well, does that mean that I shouldn't be on my Zoloft? Does that mean I shouldn't be on my Prozac?
[00:35:52] Meanwhile, as I say to my patients, Zoloft is one piece of the larger puzzle of your health and wellbeing. If it is helping you tolerate the anxious thoughts and feelings and the cognitive distortions that then allow you to get more out of therapy, that allow you to activate on the recipe for feeling better, then that is an entirely appropriate medication. It doesn't mean you're mentally ill if you take medicines and you're mentally well if you don't take medicines. It's just a piece of the puzzle, just like being in nature and exercising. So I think it's important to be clear that just because it's not true that these phenomena are chemical imbalances, it can still be true that medications can help. This is where the nuance gets lost. Because if you're someone who believes in the middle ground, where biopsychosocial elements intersect, you run the risk of people misunderstanding and thinking that you are anti-medication and that everything in our world is fixable with willpower, thoughts, and behavioral modification when that's not true.
[00:37:04] Dr. Zoffness: Yeah, I think that's why it's so important to say like there's always a bio component to everything. Of course genetics matter and you know, of course neurotransmitters matter. But I think the message, the take home message here is that whether it's depression or anxiety or diabetes or migraine, there's always a recipe of factors that are contributing every single day. And we know that because what I like to say to my patients is like, if you tell me certain times over the course of the day that pain goes up and pain goes down, or if you monitor your pain over the course of the week, you know that there are certain times that pain goes up and pain goes down.
[00:37:37] Rachel: And what that means is that if pain is always changing, Pain can change. If pain can change, then pain can change. And what that means in any given moment or hour of your day or your week, there's different bio psychosocial factors that are contributing to your pain recipe. So times when your pain is low might be you're distracted, you're with friends, you are watching a funny movie and shoving ice cream in your face and during that period of time, those two hours, your pain volume is a little bit lower. Your pain volume might be higher when you're driving to the doctor's office for a procedure that's upcoming and you're feeling really worried and you feel your heart is racing and your body is tight, and of course we know that those are gonna contribute to a higher pain volume. So it's always all the things working together. It's never just one thing.
[00:38:24] Dr. McBride: This morning I was talking to Lisa Damour about anxiety, and I think there's some parallels here with pain. Insofar as some anxiety is helpful and productive. In other words, if we didn't have anxiety, we would walk into traffic. We would not turn in our term paper. We would not veer away from the bus that's coming at us. Anxiety is a problem potentially when it's out of proportion to the actual threat and takes on the life of its own. Pain too has a function. I mean, it's a warning signal. It's telling us that, you know what, you've stepped on a thorn. You have arthritis in your knee, that maybe means it's time for an evaluation of your surrounding muscle structures and maybe you need a new knee. So how do you describe to patients, when pain is okay or enough and when we should tolerate it and when it's not enough? Because a pain-free existence is impossible.
[00:39:20] Dr. Zoffness: Yeah, so I like to always talk about pain as the body's danger detection system. It's our warning system, right? So as you said, you put your hand on a hot stove. If you don't get those danger messages, you'll leave your hand on the. Dove and your skin will melt off. Or you go for a run and you break your ankle and you don't stop running and seek help and rest so your bones can repair, you're screwed. You're going to further damage your body in bones and tissues. So pain is a very important danger message. And I remember when I was an undergrad at Brown, I had this wonderful professor, Mark Bear, who I talk about all the time now because his neuroscience textbook changed my life. And he would talk about how some people are born without the ability to feel pain like this congenital insensitivity, this high threshold.
[00:40:04] And I remember thinking, gosh, that sounds so. Lovely. And then he went on to say, and they don't live very long because again, if you imagine you, you damage your body, but your brain doesn't give you any of these warning messages or these danger messages. You're not gonna live very long. So pain is important and we have to pay attention to pain.
[00:40:23] So acute pain is pain that's three months or less. And acute pain is like the pain of childbirth or like you get a virus and you have muscle pain and then it goes away. Or the pain of a broken bone or torn ligament—that's acute pain. Chronic pain is pain that lasts three months or longer or beyond expected healing time, which is very nebulous and the definitions are just not that great, but pain that lasts beyond expected healing time.
[00:40:52] And we know that there's a difference between these two things. And one of the ways I like to talk about this, when people come to my office, they say, well, I've been in pain for seven years, 10 years, why is my pain chronic? How did this happen? And there's a number of ways by which pain can become chronic.
[00:41:13] But one of the processes that underlies chronic pain is called central sensitization. And what that means is we talked about the location of pain construction and how that happens in our brain and we know that our brains are like the muscles in our body. The more we use certain pathways in our brain, the bigger and stronger those pathways get.
[00:41:34] So for example, for me, I played the piano growing up. I didn't really like to and I didn't really want to, but my mom would say, Rachel, sit down and practice. It's the only way you're gonna get better at it. And over time, of course, she was right. The more I practiced, the bigger and stronger the piano pathway, which isn't a real thing, but the piano pathway in my brain got bigger and stronger with time until I could sit down at the piano and my fingers would just know what to do. Right? Not magic. That's just your brain changing with time and experience and exposure. And there's a word for that, and it's called neuroplasticity.
[00:42:13] Neuroplasticity literally means your brain over the course of your life is always changing, always, even into adulthood. It's morphing every time you have an experience. It's the reason you can learn a new language, even when you're 62. So just as practicing the piano made the piano pathway in my brain big and strong, the same happens when we have pain all day long, over and over for many months and weeks and years. What happens is the more we accidentally practice pain, the bigger and stronger the pain pathway in your brain gets. And I wanna say that carefully because there's no actual pain pathway. There's a lot of different ways that pain is processed by different parts of the brain, but we know that of course circuits in the brain and neural networks get stronger with use in time.
[00:43:03] So pain pathway for the sake of this metaphor, gets bigger and stronger with use. The more and more we use it. And when that happens, we say that your brain has become sensitive to pain. And I think about that word all the time. What does sensitive mean? So if you have a dog, and it's the 4th of July, we know that of course dogs are much more sensitive to sound than we are. So when all the fireworks are going off on July 4th, all the dogs in America are hiding under our beds. We give them thunder shirts or whatever, thunder jackets so that they'll calm down and it's because their brains are very sensitive to sound. And the same is true with our brains when we become sensitive to pain over time.
[00:43:48] Small bits of sensory input from the body to a sensitive brain sound and feel very big. So for example, an example I'd like to use is for my fibromyalgia patients. You go for a picnic with a bunch of friends and you're sitting under a tree in the sun, and we can all agree that that is not dangerous. But your brain might give you very amplified danger messages anyway. So things that are not dangerous can result in a very loud danger alarm. And when, when, when that happens, we know that the brain has become sensitive. And that's a chronic pain process. That's not true of acute pain.
[00:44:26] Acute pain and chronic pain are different processes, and they're both biopsychosocial. There's bio, cognitive, emotional, behavioral, sociological factors that play into both, but it's really important to think about how to desensitize a sensitive brain once pain has become chronic.
[00:44:44] Dr. McBride: Rachel, I think we need you on every corner of America because as you opened with pain is an inevitable part of life. And when we medicalize it and put it in a box and prescribe a pill, we're really depriving people the opportunity to have access to their internal world and then have agency. And I just wonder, how are you're gonna get this message out there even more than you already are. You were on the Ezra Klein show. You've written this phenomenal book. You're talking to me today. You are making a difference every day with your patients, but like I want you to have a megaphone because this is so important. It's so relevant.
[00:45:31] Dr. Zoffness: It's so relevant. I also think about this distinction between like, like you were saying before, it's like pain patients to the left and like providers and everybody else to the right and like. That's not how pain works. Pain is coming for everybody. There's no one that escapes the human experience of pain, whether you had it in childhood or you have an injury now, or you know, pain later in life. So it seems so critically important to me that we all are the holders of the truth. Like I'm just tired. Like you were talking before about, gosh, why were we all sold this big lie that depression is due to a chemical imbalance. The answer is that was a pharma marketing device. That's why that we all, we all got that message cuz it was literally plastered.
[00:46:15] I remember I lived in New York City growing up—I mean I'm a New Yorker born and bred—and there was this huge 20 foot ad on the side of a building and it said depression is not a flaw in character, it's just a flaw in chemistry. And I remember thinking, God, that's so brilliant. It's making you feel like, oh, it's not my fault, it's just my chemistry. So like if your chemistry is broken, of course the only fix is a pill. It's brilliant marketing, and we all have been sold this lie for very many decades about pain, about depression, about anxiety. It is a lie. That's not the solution. The solution is never just a pill ever, ever, never.
[00:46:53] Dr. McBride: Which is ironically not anti-pill.
[00:46:56] Dr. Zoffness: No, I'm not at all anti-pill.
[00:47:01] Dr. McBride: We could talk about big pharma all day long…
[00:47:04] Dr. Zoffness: It's just not the only solution. It's much more complicated. As humans we're just more complicated than that. Right. We're not just chemistry, we're more than that.
[00:47:11] Dr. McBride: To close. I want to ask you about you. You told me a little bit about your pain recipe and what you do to manage discomfort, psychological, biological. What are the sort of biggest insights you've learned from your own patients, who I find my best teachers. What have you learned from your patients about how to care for yourself?
[00:47:34] Dr. Zoffness: Two different answers to that question. The first thing that comes into mind, just what have I learned from my patients has been this, I don't believe necessarily in magic or miracles, but when I see teenagers get out of bed and go back to life, like I told you about this patient that I had who had chronic pain all over his body and chronic migraine and went back to soccer and went back to school. And what I didn't tell you, he got asked to prom when he went back to school, not by one girl, but by two. And watching this kid, he invited me to his graduation and at his high school graduation, he got on stage and said, if you told me four years ago I'd be graduating high school, I never would've believed you.
[00:48:17] And this magic miracle is just science. I don't have a magic wand, it's just disseminating this information about what pain really is and how pain really works. And I see it every day as my patients get out of bed and back to life. And it's it's what galvanizes me to do things like this. I actually am a library mouse and I do not like public speaking, but I can do it here with you because it's just you and me, so it's fine. It galvanizes me to go out into the world and just spread the message. You have to bridge the gap between physical pain and emotional pain if you want to treat pain because it's this lie in Western medicine that either your pain is physical and you see a physician or your pain is emotional and you see a therapist, and that's never how pain works ever. Emotional pain is physical. Anyone with anxiety can tell you how physical. That pain is, you have chest pain and you know there are times your body hurts and your sweat. There's so many physical parts of emotional pain and physical pain is emotional. People with chronic pain have 50% higher rates of depression and suicidality. Physical and emotional pain are connected always. So the biggest message I get from my patients is that this is real and we all need to be practicing it.
[00:49:35] We can't just be talking about it theoretically. We all need to go back into our offices or to our doctors or to our patients and reframe this thing that has been broken and put it back together, and it is doable. It's absolutely positively doable. And the most important message I want to convey is that chronic pain is always treatable. Anyone who tells you that it's not doesn't understand pain. Chronic pain is always treatable. There is always hope for treating pain. Always.
[00:50:04] Dr. McBride: So tell me, Rachel, where can people follow you?
[00:50:06] Dr. Zoffness: I am on Twitter. What is I think actually how we initially connected, I think I commented on one of your posts. I'm @DrZoffness on Twitter. I also do a lot of pain education on Instagram. I'm @therealdoczoff which is very funny cause I picked that initially as a joke. I joined, I think, maybe at the end of 2019 and didn't actually do anything there and just planned on following some of my friends. But now I really am using it to disseminate information about pain. And I also have, uh, websites, just my last name, zoffness.com and there's a ton of free resources. It's super important to me that pain information and treatment is affordable and accessible to everybody. I'm so tired of this lack of insurance reimbursement and it's really, it's unacceptable. There's an entire resources page with books and videos and websites and just a to a ton of free stuff.
[00:50:59] Dr. McBride: And then there's your, there's your workbook, which is just such a great resource.
[00:51:02] Dr. Zoffness: yeah, the Pain Management workbook is on Amazon and it's on my publisher's website, their new Harbinger. It's just called the Pain management Workbook. I figured go simple!
[00:51:11] Dr. McBride: It's great. It's great. Rachel, I want to say thank you so much for joining me today. You're an inspiration and I wish it wasn't true that you're a rare bird in this medical system, in this country, but I think it's pretty rare. And I think that's why I reached out to you. It's why I connected with you. It's why I've been so excited to have you on the show because it's really a crying shame that this is unusual information when it's basic human 101.
[00:51:40] Dr. Zoffness: I Totally agree.
[00:51:41] Dr. McBride: and you do such a good job of explaining it. So, Rachel, thank you so much for joining me. It's been a pleasure.
[00:51:49] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected].
[00:52:11] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
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If you’re anything like Dr. McBride or her patients, you want to live a long life. You want to be healthy! Yet when you try to execute on your best intentions—whether it’s cutting back on alcohol, starting an exercise routine, or taming your phone addiction—you end up defaulting to factory settings.
Well, you are not alone.
The pandemic laid bare how wired and tired we are—and how desperate we are to feel better. We scroll endlessly online for wellness advice and health hacks. We grab quick hits of dopamine through sugar, shopping, booze, or whatever gizmo social media is offering up. We are sleepless and irritable and don’t know what’s wrong.
The U.S. medical industrial complex is failing people. The wellness industry is fleecing people. How do we get ourselves “unstuck” when we don’t know what questions to ask or who to trust?
Dr. McBride argues that first, we must first redefine “health” as more than a set of laboratory tests or a single visit to the doctor. To her, health is a process, not an outcome. Health is about having awareness of our medical data, acceptance of the things we cannot control, and agency over the things we can control.
She calls this the “Three As.” She argues that articulating our Three As allows us to more accurately tell our story. An honest reckoning with the Three As can put us back in the driver’s seat of our health.
In this week’s (short!) solo podcast, she explains this in more detail. She defines each “A” and suggests a way to move through this process on your own.
Spoiler alert: getting healthier isn’t particularly sexy. It’s often not very fun. It usually isn’t usually quick, and it never involves a “fix.” In reality, staring down the facts, accepting hard truths, and then challenging our beliefs and our everyday behaviors is arguably the deepest and hardest work we do.
Our stories live in our bodies. What’s yours?
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, review — and enjoy — the show!
The full transcript of the show is here!
Dr. McBride: Hello, and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today, it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.
[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things. A framework to evaluate their risks, access to the truth and data, and tools and actionable information to be healthy, mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.
[00:00:55] So today it's just you and me. I am pretty excited, because I get to talk to you the way I talk to my patients. Specifically today, we're going to talk about how we might approach the process of getting healthier. If you're anything like me or my patients, you want to live a long life, right? You want to be healthy, you want to feel good, and you probably know that there's some things you could do to be healthier, but you find them hard to do, and you default to factory settings on a day-to-day basis.
[00:01:30] Well, you're not alone. Many of us aspire to get more exercise, to eat better, to get more sleep, to manage stress. In other words, we all want to do what our doctor tells us to do, but when the rubber meets the road, it's actually pretty darn hard. So how do we actually get healthier? How do we mind that gap between our best intentions and the execution part?
[00:01:53] So let's first talk about definitions like, the definition of health. Unfortunately in the US, we kind of think of health as the sum total of our lab tests. If we have normal cholesterol and a normal weight, we're healthy. But health is not just an outcome. It's not just about the absence of disease or pain, it's also not about pleasing the doctor or winning your annual checkup.
[00:02:19] After all, as humans, we're not just a set of boxes to check, a bag of organs to fix. We are the integrated sum of complex parts, and the US healthcare system just does not do a good job of countenancing the whole person. There's such a focus on extending life, which is of course good, but at the expense of thinking about our quality of life.
[00:02:41] And unfortunately in this country, by the time most people are seniors, they have a doctor for every body part, a pill for every symptom, and no one is talking to each other. No one is talking to the patient and asking them simple questions like, how are you, Mr. Roberts? What is your story? Are you okay?
[00:03:00] What are your goals? What's your North Star? What gets you out of bed in the morning? What do you live for? And by the way, how do you define health yourself and how can I as your doctor help you get there? In fact, a lot of people, regardless of age, are walking around feeling completely disenfranchised from the medical system and disenfranchised even from their own bodies.
[00:03:26] In fact, 80 million Americans don't even have a primary care doctor. So what is health? How do we define it? Health, to me, is a process. Health is about our everyday thoughts, feelings, and behaviors. It's not just about that single point in time in your doctor's office standing on the scale in a gown. It is about the 364 days a year you're not in the doctor's office.
[00:03:53] This is where I get really excited, this is why I'm here, and I can't wait to tell you about what I call the three A's. The process of becoming healthier from the inside out. It's not easy, but it's necessary for health. In my opinion, health is a process of laddering up from awareness to acceptance to agency.
[00:04:19] So I'm going to say that again and then we're gonna break it down. Health is the process of laddering up from awareness to acceptance to agency. So what do I mean by that? First, let's start with awareness. Awareness is step one. Awareness specifically is of the facts, awareness of the facts and data. When I say facts and data, I mean metrics, physical, quantifiable information that we can measure and see.
[00:04:50] I'm talking about your cholesterol levels, your blood sugar, and your diabetes testing, your weight. I'm talking about the results of your mammogram, your colonoscopy, the PSA test if you're a man, your genetic testing when you went to the geneticist because of your family history of breast cancer. These are the things that we can hold onto because these are the things that we can see, that we can quantify and that we can measure. And this kind of traditional medical data is essential to know for our health.
[00:05:19] But guess what, it's not sufficient and there's actually more data we need to collect. Quantifiable information that often gets missed in the doctor's office. Things like, what is your family structure? Are you a middle child? How were you raised? Were you raised in an urban or rural setting? What were your environmental exposures as a kid?
[00:05:40] Were you raised in poverty? What was your socioeconomic status? What about your job? What are the facts of your employment situation? What are the facts about your children, your parents, and your family's system? What is your cultural background? What are your religious beliefs? What about your educational status?
[00:05:58] How many pets do you have? What we need to gather are facts about you historically and currently that are unequivocally true. So this is step one, gathering facts and data, finding out what is true and putting these facts in a box. Now modern medicine is happy for you to stay here, for you to measure your health as the result of your lab data.
[00:06:22] Medicine is happy not to consider the other contextualized facts I just went over about who you are, what happened to you, and what are the realities, factual realities, of your life. In fact, modern medicine is delighted for you not to climb the ladder any further and to keep you stuck in the lobby.
[00:06:42] But let's not stay stuck. Let's do it. Let's ladder up and let's talk about acceptance as the next rung of the ladder. So this is where it gets hard. This is where people push back. This is the common sticking point where people have a hard time, and this is where we get into some of that magical or even delusional thinking that guess what, we all do.
[00:07:05] This is where the rubber meets the road, and it's where we have to acknowledge facts that are unpleasant, that are ugly, but are true. And this is where we have to cope, or else we get stuck on the first rung of the ladder. When I am talking about acceptance, I mean making peace with the things we cannot control, accepting the things we cannot change, and that is hard. For example, let's talk about your biometric data.
[00:07:36] You might have high cholesterol readings despite being an avid runner, eating vegetables and a vegan diet, you have no body fat. Yet your cholesterol levels just won't budge. And you may be really ticked off that you can't exercise your way out of this fixed reality. You might even have to take Lipitor because of your family history of premature heart disease.
[00:07:59] And in the meantime, you might be like one of my patients who's trying to exercise their way out of this fixed genetic reality. Running yourself ragged, blowing out your knees on the running trail, popping a bunch of Advil, when what you really need for health is less running, some physical therapy for those knees, and a dose of acceptance about your genetics.
[00:08:23] So the first part of acceptance is really looking at all that data and the awareness box. Shining a light on those dark corners, looking at things we don't necessarily want to see but that are true, and we have to cringe and we have to swallow our pride, and we have to recognize that we do not have control over every aspect of our bodies, minds, health and life.
[00:08:48] We just don't. There are things that were given to us like genes. There are things that happen to us like trauma or neglect or bad breakups or hard times. And then there are environmental factors, family dynamics, birth order, special needs kids, aging parents, things that we are exposed to that we cannot change and we cannot control.
[00:09:11] And it's when we start to accept the things that make us human and the sometimes unpleasant realities of our lives—that is the birthplace of health. So here's where I want to say very clearly that acceptance is not about giving up. Acceptance is not about throwing in the towel. It's about making peace with the things we cannot alter and change in our lives.
[00:09:36] Acceptance is not about being passive. It's about taking active control over the finite resources of our body, mind, and spirit. And so whether it's things that are innate, that are biologically fixed or that are emotional, behavioral, social, or even structural in nature, acceptance is about reclaiming the energy and brain space that is occupied by trying to change the things we cannot change, and then moving that energy into a more positive, productive place.
[00:10:12] It's about taking charge. It's about being in the driver's seat of our health. Now, no one is saying that acceptance is easy. In fact, like I said earlier, this is where most people get stuck. And we don't often even know that we're stuck. But this is where we all get stalled out. Accepting things that we don't want to accept and that we desperately want to change, whether it's about ourselves or what happened to us or about other people or our environment is an extremely hard thing to do.
[00:10:46] It's a process. It can be painful, and we're also never really done with the process of acceptance. But I will say it again, that acceptance is a necessary process of becoming healthier from the inside out. It's essential for minding the gap between our best intentions and the execution of them.
[00:11:08] Acceptance is also part of this laddering up process to be able to more accurately tell our story to ourselves, to the people around us and then to our doctors. All right, so let's move up to agency. Agency is the next rung of the ladder. Agency is where it gets fun. It's a little sexier. It's where the action is, there's movement, there's momentum.
[00:11:31] But remember, we can't get to agency before we have worked on acceptance. Why? Because we've jammed up all of this real estate in our brains by trying to control the things we cannot control. So here's the cool thing. Once you have put all of those facts and data into the box and you've accepted the things you cannot control, everything else is fair game.
[00:11:53] Everything else is changeable. You can actually change the way you think, the way you feel, the way you behave. You can actually rewrite your story. You can tell a more accurate version of your story that is rooted in facts with all the junk and waste cleared out of the way. So what is agency? Agency refers to our capacity to exert control over our thoughts, feelings, and behaviors.
[00:12:21] We all wanna live in that agency space. We all wanna make changes, be better. New Year's Day is a perfect example of aspirational, almost delusional agency at its finest. It's when people newly sign up for the gym, they drop the booze, they commit to yoga, I'm gonna start meditating we all say to ourselves. We're trying to get from point A to point B.
[00:12:43] We're trying to make changes to be healthier. But if we haven't taken the time to understand the facts, the realities of our lives. And the medical data that is actually part of our health makeup, and if we haven't gone through the exercise of separating fact from fiction and accepting unpleasant parts of ourselves that we cannot change, then agency is gonna be uniquely challenging.
[00:13:07] We are going to set ourselves up for failure, and by the time February rolls around the wheels come off the bus. And despite our best intentions, we default to factory settings, trying to get things done, and we're wondering why the hell don't we feel well? So that's normal. That is human, and this is what I see every day.
[00:13:24] This is what I do myself. Instead of being intentional all the time, I'm reacting to what's happening in my external and internal world, and I spend a lot of wasted energy trying to control the stuff I can't control instead of leaning into the parts where I do have control and understanding where I have agency.
[00:13:41] Let me give you an example of a patient I recently saw, and I'll tell you how we walked through the three A's. So, this patient is a middle-aged woman who's overweight, she has an arthritic painful hip, and she comes in to see me and she says to me, “Dr. McBride, I really wanna lose weight, but I can't. I can't exercise.
[00:13:58] It's driving me nuts and I don’t know what to do.” So we go through her data. She has high cholesterol, she has pre-diabetes. Her BMI is in the obese range. On her x-ray, she has bone on bone arthritis. Some of her data is favorable. She has healthy lungs, she has a healthy heart. She has a stable job, a supportive spouse, and really good health insurance.
[00:14:21] Other facts and data that we gather are that she has a very busy job, a long commute, and a gym that is very far from her home and work. She's also a parent, and notably, her mom had a hip replacement for severe arthritis that went badly, and her mom ended up seriously ill and quite depressed.
[00:14:41] As an oldest child she likes control, and she worries a whole lot about her health, and finds herself overeating at night because of worry. So those are some of the facts about this patient's health. In order to get to acceptance, the next rung of the letter, we need to take all of those facts, put them in a box, and then take a hard look at each piece of data and figure out what we need to accept because we do not have control over it.
[00:15:07] For example, we have to accept the sad reality that her mom had a bad outcome from a surgery that my patient herself needs. But we can look at the facts of her mom's situation. We also have to accept the fact that her weight and her relative inactivity because of her hip, are driving her high cholesterol and her diabetes testing.
[00:15:27] In fact, when I knew her 10 years ago and her weight was more normal and she was exercising more regularly and eating more intentionally, her cholesterol and her blood sugars were normal. So we know that these biometric pieces of data are dynamic and they're dependent on her level of movement and diet.
[00:15:45] In other words, we are not going to accept that she is destined to have heart disease and diabetes. However, we need to accept the fact that this arthritic hip is not going to get better on its own. That there's no amount of Advil or waiting it out that is going to get it better. So it's time to accept the fact that this is now a surgical problem.
[00:16:04] We also need to accept that she has this habit of overeating when she's anxious. We can accept that. But what we can do is work on the anxiety and the fear itself. Let's move into agency. Now that we have accepted these realities of her life and these parts of her health that are unpleasant, and we've decided not to accept that she is destined to have high cholesterol, diabetes, and a limp for her whole life, and she's not destined to become her mother, we can lean into the agency and put her back in the driver's seat of her health.
[00:16:38] And then we're going to talk about how to rebuild trust in orthopedic medicine and how to find her a physician who will listen to her concerns, and help her get the treatment she needs. We're also going to go back into her laboratory data from 10 years ago, and we are gonna look at the facts around her habits when her cholesterol and her blood sugar were normal, and we are going to forecast her being able to move and live her life the way she wants to, to be able to bring those numbers down over time.
[00:17:08] But in the meantime, given her age and her family history and her predisposition to heart disease, we are going to add a small dose of Atorvastatin to bring her cholesterol down under 100, which is the standard of care for someone in her situation. Now I remind her that when she gets that new hip, when she is able to go back to her swimming, her dance class that she loved so much, and when her cholesterol levels come down, we can always pull that cholesterol medicine away.
[00:17:39] In other words, let's meet the fixed unpleasant realities of her life that she cannot exercise right now. And let's treat the medical issues using evidence-based medicine, and let's follow up and change that recommendation as the conditions change. And as for her natural anxiety about having to have surgery, about her anxiety about her health, I'm going to recommend that she start journaling, prioritizing sleep, and consider seeing one of my great psychotherapists, to help her reroute those hardwired, almost reflexive patterns of thought, feeling, and behavior.
[00:18:12] Like, I feel scared. I am scared. I'm gonna go eat something I regret later. And to help her rewrite her own story so that she is in control of her mental and physical health in tandem. The overarching goal here is to help the patient rewrite the story that she has told herself. That she is broken, that she is obese, that she is incapable, and that she's going to become her mother.
[00:18:36] That story, it’s a story she's told herself again and again, and that can be rewritten when we go through the process of the three A's. As I talk about a lot, our stories live in our bodies, and it's when we are able to do an honest retelling of our stories, and fact check the stories we've been telling ourselves, that's when we can start to work on accepting things we can't control and where we get to open up the door to more agency.
[00:19:05] Okay, so what's the take home? What is the upshot for you, dear listeners, after you've listened to this diddy about the three A's? Here's my advice. Grab a pen and an old fashioned pad of paper. Think about a problem you have in your health or in your life, and then write down the narrative you have about it.
[00:19:26] Write down this story in your mind about the reasons you cannot solve this problem. Write down in a very honest, sober way, about what are the facts about this condition? Have you gathered all the facts? And then go through this exercise. Find the facts, whether that involves your doctor or asking your parents about your genetic history, or asking your spouse or your kids or yourself about the facts of this condition.
[00:19:53] Maybe it's a heart condition, maybe it's arthritis, maybe it's depression, maybe it's alcohol overuse. Whatever it is, and bring it to your doctor and see if an honest telling of your story helps you squeeze the juice out of the medical system, and helps you get a little healthier from the inside out. Over the next couple of weeks and months, I'm going to be fleshing this out a bit more.
[00:20:18] I want to talk a lot about the acceptance part and why that is so hard. How do I help people learn to accept the things they can't control? Where do people get stuck and what is all this magical, delusional thinking that we all do? Let's hash it out. And then let's talk more about the agency part. Let's talk about how we mind that gap between our best intentions and the execution. And why we can't get to the other side.
[00:20:42] So I'd love to help you. I'd love you to stay tuned. In the meantime, join me on my Substack at lucymcbride.substack.com/, and I would love your comments about this podcast. Drop me a note below. Tell me what you think. Tell me what you'd like to hear more about. I will see you next time. Thank you so much for joining me.
Get full access to Are You Okay? at lucymcbride.substack.com/subscribe -
Why are expectations about being a woman—specifically a mother—so unrealistic?
Mother, author, and New York Times opinion writer Jessica Grose has a lot to say on this subject. Her latest book, Screaming on the Inside: The Unsustainability of American Motherhood, is inspired by her own shortcomings as a mother. She interviewed hundreds of women as part of the research process while writing the book. In it, Jessica shines a light on the current state of motherhood, and the historical context around the impossible standards for American mothers.
In honor of Mother’s Day, Jessica and I sit down to discuss the narrative and messaging to parents that “they’re doing it wrong.” Jessica urges parents to learn to trust their instincts and to show up to parenting as their authentic, imperfect selves.
Join me every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, review — and enjoy — the show!
Transcript of the podcast is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I’m Dr. Lucy McBride and this is Beyond the Prescription, the show where I talk to my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for more than 20 years, I’ve realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies. I’m here to help people tell their story, to find out, are they okay, and for you to imagine, and potentially get healthier from the inside out.
[00:00:45] You can subscribe to my weekly newsletter at lucymcbride.substack.com and to the show at Apple Podcasts, Spotify, or wherever you find your podcasts. So let’s get into it and go beyond the prescription.
[00:01:01] Dr. McBride: Today I'm interviewing Jessica Grose. She is a mother, she is an author, and she is a New York Times opinion writer who writes a lot about parenting. Her most recent book is called Screaming on the Inside: The Unsustainability of American Motherhood. I was immediately drawn to this book because it was inspired by Jess's own perceived shortcomings as a mother, something I think a lot of us women can relate to. The book combines in-depth interviews with mothers and a historical context on motherhood to help explain why our expectations about being a mom are so unrealistic.
[00:01:37] I think there's a narrative that a lot of us women and mothers absorb that if we only read the right book, if we only had the right parenting expert on speed dial, that we could be the perfect mother when it's not that simple, and frankly, we need to be better able to trust our instincts to know that by showing up, by being a good person and by leading with empathy and curiosity about who our kids are that we are good enough. Jess, I'm thrilled to have you today. Thank you so much for joining me.
[00:02:07] Jess: Thank you for having me. I just wanted to mention, we actually recently dropped the on parenting. I will still talk about parenting. I think my last column was about parenting related issues, but I wanted to have a chance to broaden my aperture a little bit, write about all sorts of issues, mostly cultural, but it's been exciting and I'm really looking forward to this year.
[00:02:30] I mean, an example of that was I just did a big piece about midlife and millennials at midlife. I am one. I am an ancient millennial. I just turned 41.
[00:02:39] Dr. McBride: What's the newsletter called now?
[00:02:41] Jess: It's just my name, just Jessica Grose.
[00:02:43] Dr. McBride: Okay, awesome. How cool is that though, Jessica, that you got to move from being a reporter, which I know you loved to giving your Opinion. I mean, anyone who knows me will tell you that. I love data. I love analysis. I love pouring through primary sources. I also have a few opinions and I love delivering them.
[00:03:04] Jess: Well, I don't think that my approach has actually changed really radically. I do what I like to think of as reported opinion. It's unusual for me to just riff on an idea without including data or including interviews. Occasionally I will actually, my next column is just about Brook Shields' new documentary. And so that's more just thoughts about what it’s like to grow up in the public eye for a kid. And it’s unsurprisingly not great. It was really difficult for her to develop a sense of an identity. But typically I still do a lot of reporting. What it allows me to do is draw more aggressive conclusions from that reporting. And anyone who knows me in real life knows I have a lot of opinions, so it feels really nice to share them.
[00:02:52] Dr. McBride: Well, I think that's right. It's the same thing in medicine. I have a lot of opinions, but it's rooted in my understanding of the medical literature and the understanding of the patient in front of me. So I'm never going to just say, do this because I said so. The fun is taking the data and the data in your case on motherhood and the historical context around it, and then giving parents and mothers permission to be less perfect than their Instagram highlights might suggest they should be.
[00:04:23] Jess: Yeah, I mean I had just the genesis of the book was really just in having so many questions about where ideas that I had about motherhood came from. Because when you start to unpack them, they sound crazy. So one example that I often give is I was very sick during my first pregnancy. I had hyperemesis, so I was throwing up constantly. I could not keep food down. I got incredibly depressed and anxious. I honestly think in large part because I had hyperemesis, just as you cover, the body mind connection is very deep. Not being able to nourish yourself, it's tough to feel good in any way. And I had the question, why is there even the expectation that one should feel good during pregnancy?
[00:05:16] Because I've known a lot of pregnant people in my life, and most of them do not feel great. Maybe they have moments where, during the second trimester, they're not enormous yet. They're feeling a baby kick. They're not sick anymore. Maybe you’ve got like two months of feeling pretty good, but often, there are many ways in which you can feel not your best self, and so every chapter of the book started with a question about an ideal that when you think about it for more than five minutes, makes absolutely no sense.
[00:05:49] Dr. McBride: Yeah, it's interesting about the hyperemesis, and I heard you say in an interview that you leaned into the toilet, that was your lean in. So I had a patient recently in my office who is pregnant with her second child. She's in her second trimester, and so, so sick, like on her knees, in her bedroom. She's a congressional staffer and can't even really go to work most days because she's so sick. And she went to her gynecologist and she was explaining how sick she was to her gynecologist, her obstetrician, and my patient asked the question, “can I take Zofran or something for this nausea?” And the doctor said to her, and the patient's crying telling me this story, she said, “well, if you really can't function, I guess you can take some Zofran.”
[00:06:31] That's a tough standard to hold ourselves to. If you're in the fetal position, then you can treat yourself to a medication that's exceedingly safe, particularly in the second trimester. Why are women so conditioned to suffering and why are we depriving them of the permission to experience highs and lows of pregnancy and motherhood, I don’t know.
[00:06:55] Jess: Well, we're working against thousands of years of conditioning, right? I mean, the idea that mothers shouldn't be martyrs and sacrifice themselves, put themselves last in every situation. That is in all of our in some ways all of our religious texts of the major religions, it is there if you want to pick it up. I mean, in terms of pregnancy and the benefit risk analysis, I think particularly in the United States, and Emily Oster is obviously the guru on this topic, we have just over-rotated on risks and perceived risks because statistically speaking, many of the things we think of as scary and we shouldn't do them, are not damaging really at all, except in extremely unusual circumstances.
[00:07:45] And so I think medication is one of those things, and particularly things that are seen to be non-essential. And it's always a question, well, it's like, well, non-essential for whom, and one of the big mental health related medications, it's even more for, where it's like Prozac in particular is that there's so many studies on SSRIs in pregnancy. So, so, so many and perinatal psychiatrists will tell you that the risk profile for those drugs is pretty good. Everybody needs to make that calculation for themselves. I am not pro or anti-drug. I'm pro making an accurate risk benefit assessment in every individual
[00:08:31] Dr. McBride: You sound like my friend Emily Oster, and you sound like, and you sound like me, because Emily's a good friend and she was on the podcast and we've talked extensively about the level of scrutiny that we expect women to look at these risks with is exceedingly high. Eating blue vein cheese during pregnancy, having a thimble full of wine. Those carry risks, but so do being anxious and being depressed.
[00:08:59] Jess: So does getting in your car every day, which [00:08:00] is probably the most dangerous thing that you do as a pregnant woman. That's typical. But we don't think of it that way because of complicated reasons. And I do think it's affecting not just how we feel in our own bodies and how we experience the pregnancy and postpartum period, but I think it's affecting how we parent and it's making us more anxious parents than we need to be. And to me, the joy of being a mother is watching my kids become who they are and watching them go out into the world and navigate it. And excessive anxiety about things that have risks but low risks really impedes relationship building that joy of watching them become their own people.
[00:09:50] And that just makes me incredibly sad because it should be joyful. Not all the time. That's a big part of my book. Parenting is not joyful all the time, but there are parts that are incredibly joyful and validating. And so I think having too aggressive a feeling about risks and a scary world out there impedes the joy that we could feel.
[00:10:15] Dr. McBride: Yeah, I think we learned in Covid that people in general do a pretty bad job of assessing risk. And then thinking about risk benefit ratios, we tend to overestimate risk when we're thinking about our children and we think about women.
[00:10:31] Jess: Yes, and I don't blame anyone because the avalanche of information that all of us are getting all of the time, no one can parse that. You don't know who to trust. I feel lucky that I gave birth to my older daughter in 2012 when the social media ecosystem was not—I guess I would describe it as broken today. There were problems with it, but it wasn't, there just was less social media. There were no Instagram stories. TikTok didn't exist. It was not what it is today, and I made a concerted effort knowing myself that I tried and really didn't look for parenting information online. I did not follow any parenting as much as I could. I had one book, and the only book was the Mayo Clinic's Guide to Your Baby's First Year. And if I had a question, I would ask my pediatrician or I would ask my mom, and that's unfair to expect everybody to do because my mom is also a retired physician.
[00:11:31] Dr. McBride: You have an advantage.
[00:11:33] Jess: I have a home court advantage in terms of trustworthy, you know, people in my life. But I think paring down that is one thing I tell parents all the time. Pick a few trusted sources and just try to block everything else out because otherwise you're gonna drive yourself bananas.
[00:11:53] Dr. McBride: I think it's great advice, because of all the information coming at us like a open fire hose, and because there's so much fear-based messaging and because we're predisposed to being more anxious about our children and society has made women more anxious about themselves for whatever reason. How do you guide people on deciding who to trust and who not to trust? What's the anatomy of trust in your mind?
[00:12:16] Jess: So, I mean, number one, and again, expertise does not always equal trust, but always look at the credentials. Look at their credentials. See as much as you can. If they have a particular narrative on any topic that they are trying to push, see if they have any conflicts of interest in terms of payment through a certain company. All of the things that… it's sort of a journalistic way to look at the sources that you trust. And then the sort of X-factor is more just vibes. Are they making you feel bad about yourself? That's huge. So many advice givers on social media are invested in negativity.
[00:13:01] Actually, there was just a great article in Vox about this, not specifically targeted at mothers, but saying, because negativity plays better in the algorithms telling you that you're doing it wrong will rise to the top and that's just not how I wanna be talked to about my parenting. Like, “you're doing it wrong and this is the right way to do it.” Well, piss off! My spirit is very contrarian. And so if anyone is telling me like, you're doing it wrong, I have just an immediate gut [reaction]—I'll do what I want. I've talked to so many people through my reporting days that they have the opposite reaction, which is like, I must be doing it wrong and I feel terrible. So if something's making you feel terrible, listen to that voice.
[00:13:45] Dr. McBride: I think women walk around with that narrative on their own. They don't need help in many cases. I think so much of our messaging to women the historical context around this is about you're doing it wrong. You could be better. You're not enough. Your kids are messy, your kids are loud, your kids are emotional, your kids are this. And then of course we feel anxious. Of course we feel like we're not good enough. And so we have this narrative often that is, we are not doing it right, we're doing it wrong. And that is a narrative that dies hard for so many people and does inform the way they show up in my office as patients with insomnia, alcohol overuse, distress and malaise. The pressures we put on the American mother are enormous, and it's not like it is in other countries. Other wealthy countries don't have the level of scrutiny on mothers like we do in this country.
[00:14:41] Jess: And I think there's been cross-cultural studies done on this, and parents in our peer nations actually look to experts less for advice because they feel more supported in their own communities and they feel more confident in their own instincts. And I think that there's a lot of complicated reasons why that is.
[00:15:01] Dr. McBride: Could you talk about why you think that is?
[00:15:03] Jess: Well, I mean, I think, you know, they orient their entire societies around children being more part of the day-to-day and having children behave as children do is just understood. It's not demonized. It's not, you're not worried all the time, that's everybody's gonna give you nasty looks in a restaurant.
[00:15:29] It's like children are just sort of more welcomed as a baseline. And I do think that. There's a relationship—it's not a one-to-one relationship—but there's a relationship between that attitude and having more child-centered public policy. So everything from paid leave, which we are the only wealthy country in the world, that doesn't provide it for our citizens. More subsidized child care to things like even urban design, having more parks and green spaces, having more walkable areas for, and areas for children to exist and play and be more a part of society.
[00:16:10] I did a piece about this adorable Japanese show that's on Netflix called Old Enough, and when I was researching that piece, the show depicts toddlers, really little kids going on their first errands alone, which, just would never happen for a million reasons in the United States. But part of the reason that it is easier for Japanese children to be more independent is because of the built environment in Japan. And there's a great article in Slate about that. So, those are things that are sort of subterranean. We don't even see them. We don't think about them. We obviously are not all so well traveled that we know what the built environment looks like in Japan, but those are some of the reasons that I think American parents do feel such a sense of scrutiny and need and desire to seem perfect or keep their kids perfectly in line when they're out in public.
[00:17:11] Dr. McBride: Do you think there's something to the idea of women in America not trusting their instincts as much, or not being allowed to trust their instincts? I mean, what I see since I became a parent, and it's the same problem in the wedding industry, is that there's a whole professional industry around parenting. I'm so glad I got married in 2000 and not today because we didn't have one of these produced proposal moments. It was just a casual moment in the woods. Similarly, when I was a parent for the first time, I didn't have Instagram and all the parenting gurus out there. I just had to trust my instincts. But I think because we professionalize these phenomena, women can start to feel less than, or like they have to read this book and then they'll be okay when actually we are born to be parents if we want to be. So I don't know if there's something about that, but it does feel to me like we often don't give ourselves permission to just listen to our intuition.
[00:18:19] Jess: Yeah, I think the sort of commercialization of everything is connected to the fact that there are no sort of communal supports and rituals. So, for example, in many countries after you give birth, Somebody from the National Health Systems will come and visit you. A nurse will come to your house and…
[00:18:37] Dr. McBride: Can you imagine that happening in the us?
[00:18:40] Jess: I cannot, I would have loved that. They will come to your house free of charge. They will make sure you're doing okay. They'll make sure the baby's doing okay. They'll help you with nursing. They'll do all of that built in support in that way. There are mothers groups that will be organized through the community and I think when you don't have that, then figuring out how to solve your problems is an individual issue, and then you feel isolated and that leads to that sort of stress and anxiety and desire for individual solutions that ultimately might not help us feel good or feel accepted. And so it all sort of is so connected to so many different aspects of how we raise children in this country.
[00:19:32] Dr. McBride: I also wonder what you think of the idea of caution as a virtue we saw in the pandemic that we really moralized human behavior. If you didn't get vaccinated, certainly you were sort of deemed a pariah of society. If you didn't mask long enough, diligently enough, there was something wrong with you.And I think when we looked at the data on Covid and kids, at least when I looked at the data, it was clear that kids, healthy kids tended to do generally pretty well with the virus, which is not to say that we wanted kids to get covid. It's not to say that kids haven't tragically died from covid, but there's something about the moralization of motherhood and behavior and children in this country that is, to me, seems unique. I don't know what you think about that.
[00:20:27] Jess: I think that's right. There's just this pervasive attitude. It's like if anything goes wrong, it is your fault, it's your responsibility, it's your fault. You should, you have to be there to pick up the pieces. No one's there to help you. You should have done X, Y, and Z differently, but it’s not working.
[00:20:44] Dr. McBride: It's not working because Jessica kids get covid. Kids do stupid stuff on the playground to each other. Kids are messy and imperfect and so are we. And so this notion that caution as a virtue is inherently flawed because there's only so much you can be cautious about and risk is ubiquitous.
[00:21:04] Jess: Yeah, I think a lot about the fact that my older daughter broke her arm during Covid. She broke her arm in May 2021, and it was because she was playing soccer in our courtyard and she fell. And there was nothing that was… we were lucky enough to mostly remain healthy during that time, but it was just like I was literally a hundred feet away from her. Things happen in children's lives. I didn't feel guilty. I felt bad for her. Obviously seeing child in pain stinks. It was a thoroughly un-fun experience for all involved, but I didn't feel responsible for it. I, but it occurred to me as I basically witnessed it happen. It was just like, there's nothing I can do. She's biting it and her arm looks really messed up. [Unless we] start placing her in bubble wrap and never letting her leave the house, this was unavoidable.
[00:22:09] Dr. McBride: That's right. I just had a thought as we were talking about risks to kids. I was remembering the article you just wrote for the New York Times about the reporting on the CDC data on adolescent mental health. And I thought it was such a great article because in my office I have parents and older teens as patients who are having mental health challenges, whether it's anxiety, depression, substance use disorders, eating disorders. I also have a fair amount of parents who are anxious about the headlines alone and anxious about the data. And then I have fair amount of teens who feel like, “oh my God, this is inevitable that I am a mentally ill person because this is what everybody's talking about.” And so what I loved about your article is that you are trying to take away the catastrophization, if that's a word…
[00:23:03] Jess: Yeah.
[00:23:04] Dr. McBride: You’re the the writer! and to frame the data and recognize let's look at the facts and look at the way the data was collected and the timeframe. And then let's also recognize the historical context around over worrying perhaps about girls having emotional health, not to dismiss the fact that kids are suffering, not to dismiss that kids are losing their lives to mental health problems, but rather to recognize the biases we have culturally that make us kind of mentally masturbate, if you will, on girls having feelings. So can you talk about that a little bit more because I thought it was brilliant.
[00:23:40] Jess: Yeah. Oh, thank you. It was a struggle to write because I really wanted to be very careful and not… the fact that suicidal ideation is up, the fact that suicides are up is awful. Full stop. We need to help those kids. Any kid dying before they're 18 is a tragedy. That is awful. And my heart absolutely breaks for parents whose kids are really struggling, you know, exactly as you say, with eating disorders, substance use, self-harm is up, cutting all, of that. So. I never want to seem like I am diminishing the seriousness or pain of that.
[00:24:24] At the same time, since I was a teenager… I graduated from high school in the year 2000. All we've had since the year 2000 is more awareness and more discussion of mental health, and I just don't want teenagers in particular, who, and being, because being a teenager is really hard. I remember being a teenager and you could not pay me to go back there. I don't want them to pathologize the normal ups and downs this period of rapid change. And I don't want them to necessarily label themselves as, oh, I'm an anxious person. I'm a depressed person. I am X, Y, and Z. Well, it's like, maybe, but maybe you're just having strong feelings and that's part of life, and that's part of being a person and you're learning how to handle them and you can handle them.
[00:25:24] You can handle these big feelings and you don't need to necessarily label yourself as having a broken brain, which is how a philosopher that I quoted describes it. She calls it the broken brain hypothesis. Oh, my brain is broken and it needs fixing. And is that narrative helpful for all teens? And I would argue, no. I am the daughter of a psychiatrist. I am pro psychiatry. I am pro psychology. I am pro therapy. But at the same time, does turning inward help everybody all the time? I think most teenagers could benefit from just as they say on the internet, touching grass, not turning inward, turning outward to their communities, to their friends, to their own habits.
[00:26:20] One thing that I had in an earlier draft, which I didn't include and I think is under discussed, there is good data on the fact that teens are sleeping less than they used to, and that is huge. They might just need more sleep. They're just tired and cranky and I mean, I've, there's been, especially when I was a new mom, there were numerous times where I really thought I was losing my mind and I was just completely exhausted.
[00:26:48] Dr. McBride I think it's such a good point, not only do we tend to pathologize normal human emotions, which is distinctly not to dismiss the harms of depression, anxiety and substance use. We also tend to make things more complicated than they sometimes are. Sometimes the solution to my patient’s angst and alcohol overuse in the evenings when she gets home from work and poor sleep and hot flashes is, she just needs to eat lunch. Same thing with what you're talking about. It's not gonna solve everyone's problems, but sleep is an essential part of the human brain and bodily function. So I think you're right. Sleep is huge.
[00:27:33] Jess: But also, I mean in terms of my researching for this piece, my attitude towards all of the ideas around this is yes, and it's not, I don't agree with that. Screens are an issue. They're absolutely an issue. That's part of this. It's how we parent and over parent possibly. I think that's part of it too. It's more just to say, I wanted to take. The temperature down a few degrees because I don't think really panicky headlines are helpful to anyone, honestly, on almost any subject. I think that's making everybody more anxious. And so I just wanted to say, can we talk about different ideas? Can we look at this from a different angle?
[00:28:18] Jess: And I have a dog in this fight. I have two girls, one of whom is entering middle school in the fall. I want her to feel confident and empowered, and I want her to feel like she can take charge of her own emotional life, and I will admit that this is one of the few times where my reporting has really changed the way I think about parenting.
[00:28:43] Dr. McBride: It’s so interesting. I want to talk a little bit more about the taking the temperature down phenomenon, because like Emily Oster, I have been writing, I mean not to the extent she has been, but about fear getting ahead of the headlines about pediatric risk, of covid, about the excessive amount, in my opinion, of rumination, about covid risks in the vaccine era at the expense of thinking about health in a broader way.
[00:29:20] And I'm talking to women in particular. I'm talking to everybody, but I think women as the ones who are largely the primary caregivers for kids and women who are, the ones that I see, at least in my office, tend to be more anxious about risk, not universal, but there's utility in doing that and trying to take the temperature down.
[00:29:42] There's also a fair amount of backlash to that narrative. People don't necessarily want to hear that it's okay if your kid gets covid because by the way they will anyway, and it's not going to necessarily do them long-term damage because that's what the data show us. There's some currency there about. The vigilance and the anxiety. It feels like having its own life, its own place, and that is what's concerning to me that, that it's really hard to let go of. Do you see that? Does that make sense to you? I know that because Emily Oster and I have discussed how we have to go into hiding when we put out these articles for The Atlantic.
[00:30:22] She wrote the article that your kids going on vacation or flying on an airplane is like the same risk as their grandparents or something like that, and she had to go into like witness protection program because people were so angry that she was trying to help people manage risk and calibrate it to the actual threat.
[00:30:38] Jess: Yeah, but I'm sure she at the same time, she also had a lot of people thanking her. I mean, it's easy to think about the backlash.
[00:30:45] Dr. McBride: I think that's right, but I also think that, I just wonder where that anger is coming from.
[00:30:52] Jess: Well, I do think that there is something to, and I'm not saying that this is a conscious feeling, but if you are not worrying about your kid, you're not a good mother. And that has to be part of the equation. And it goes back to if anything goes wrong, it's your fault. And so your worrying will prevent anything from going wrong. But you know, that's not how life works. There's terrible unlucky things that happen and that's part of un unfortunately, that is the downside of living a full life, because if you just avoid anything that is, you know, has a potential risk and even at a potential emotional risk, I think you're gonna be missing out on most of the good parts of life.
[00:31:36] Host: I think that's right. I think because motherhood is intrinsically stressful, I think we can start to associate stress with mothering, where if you're a good mother, by any definition, It's despite being anxious, it's despite being stressed, like I know that I'm doing my best mothering, which, you know, I'm not winning mother of the year anytime soon. But I feel like I'm in my best moments when I'm not [00:31:00] leading with fear or anxiety when I'm like just straight talking. But I think it's easy, like just for anybody, to, anyone who's used to like achieving or. You know, trying to do well, and we're all trying to do well as parents to associate the anxiety itself with the outcome.
[00:32:19] Jess: Right. But I think, and this is actually, I've been thinking about this a lot lately because I see a move in parenting advice towards giving people scripts. And my attitude towards most parenting advice is like anything that helps you get through the day in one piece, great. But I do wonder if we are overthinking the importance of every single word we say to our children and worrying that if you say one wrong thing wrong, I'm putting that in air quotes because who knows what even is the right thing for your individual child. It could have catastrophic blowback, and to me it's a risk of being inauthentic with your children if you are relying on some sort of words that didn't come from you or your brain, it teaches your kid that you're also not really human yourself. I think it's important for your kids to see you as a human. Obviously, they should never feel responsible for your emotional wellbeing, but they should know that you're not perfect. That's good for them.
[00:33:36] And I've written articles where I try to give people scripts when I think it's helpful, so I'm not knocking it overall, but I do wonder what we're losing if we're not just trying to speak honestly as ourselves, because are we pretending that we all want the same outcomes for our children? Like what does that even mean? What is a good outcome? I think all the time about What do you want for your kid in the world? We don't all agree because everybody's different and everybody has different values. So, I just think the challenge for all of us is to sort of live an authentic self as we are also parents. We are not some new kind of person.
[00:34:17] Dr. McBride: That's right.
[00:34:18] Jess: We're still just people.
[00:34:20] Dr. McBride: I'd love to ask you about you as a parent right now and what are your particular struggles? Are their particular narratives you have in your mind that you're trying to undo, and how are you looking to be a healthier parent for your kids?
[00:34:39] Jess: My kids are at a great ages. They're in first grade and fifth grade, and so we're out of that diapers and toddler tantrums phase, which I found. I love babies. I really liked having babies. I struggled with that one. That age between one and two. I think that was the hardest for me as a mother just sheer exhaustion, but with my older daughter who will enter middle school, something that I'm proud of is completely removing myself from any of her friendship drama. And I never got involved in terms of like talking to anyone. Of course not. But I would… she would tell me something. I would not react to her, but later I would be stewing about it. And I have just been like, stay out of it. Do not get emotionally involved because there will be a new drama tomorrow and some other girl is gonna say something to some other girl and obviously if it were a bullying situation, that would be different.
[00:35:44] But just having been a middle school girl, this is very familiar to me. And so when it first started happening kind of at the beginning of fifth grade, I was upset. I was upset, man, it stinks to watch your kid be in this mean girl business. And I don't think she was probably totally innocent and it either, who knows? I wasn't there. I shouldn't be there. And I always let her deal with it herself. I never got involved with it, but I would get really upset. When she wasn't around. And so I think it's a parenting win for me to just have let that just be like, I'm not getting emotionally involved with this. It's only gonna get worse in the next couple of years. I assume maybe I'll get better, who knows? But having been a teenage girl, this is just the beginning. And so I think training myself to not get too involved in any way.
[00:36:38] Dr. McBride: It's really healthy. And what's particularly healthy when I hear you talk about it, that you recognize your daughter may have had a role in it. You're not assuming innocence just because she's your offspring, and you're also recognizing there are harms of, you know, the dynamics that you would hopefully pick up on.
[00:35:53] But you're right, they have to kind of navigate these things themselves.
[00:36:59] Jess: They have to, and they have to learn how to deal with people they're not getting along with. That's life. That's the workplace that's going to go into, there's nothing I can do. Absolutely I can be there for her when she comes and tells me she's upset about something and if she asks me for advice. I'll give it to her. She seems to want no part of my advice about anything…
[00:37:18] Dr. McBride: Welcome to the club. Welcome to the club, my friend.
[00:37:21] Jess: but I found it very distressing when she first would start telling me about the beginnings of these sort of… it's so familiar. I'm sure you found it familiar when your kids started going through it.
[00:37:34] Dr. McBride: A hundred percent.
[00:37:35] Jess: And so it's been, now that she's almost at the end of fifth grade, I feel like I think we both have a better handle on it, let's put it that way.
[00:37:44] Dr. McBride: My last newsletter subject was about this after I interviewed Lisa Damour for my podcast. I love Lisa. She's, oh my gosh, I could just listen to her voice all day long.
[00:37:53] Jess: She has a very soothing voice. That's true.
[00:37:55] Dr. McBride: And I wrote a substack piece about how hard it is to do this, but how essential it is for us and for our children to try not to ride the rollercoaster of their emotions. Because first of all, they want us to, and that that's a little bit of a currency. I mean, they don't want us to really, but they're, they get their mojo from riling us up. But if we can have a little bit of a distance or space from their everyday minute to minute, Emotions. It's good for both parties
[00:38:26] Jess: It is, and again, it's like when I said that reporting, that piece really changed how I thought about parenting. I already felt this way to an extent, but I think not allowing our children to deal with their own problems is so bad for them. It's bad for us and it's bad for them, and we can't just, as my children get older, I want them to feel a sense of agency in their own lives. I want them to be really self-sufficient. It's really important to me. I think it's really important for them. And so, I already thought that, but there are certain things that I have vowed to do a little differently solely based on the reporting about teen mental health, just because I really do think allowing them as much independence, again, emotional and physical independence as makes sense for them as an individual child.
[00:39:28] All kids are different. All kids have different abilities. They have different desires. They have different things that they're ready for at different times. I mean, it's so wild to look at my children. And their classmates because you can see all of these kids are normal kids and they have such a range of physical size, emotional maturity, intellectual, cognitive differences that are, again, all within the range of normal, all beautiful in their own ways. And so every parent has sort of a different way to do it, but I think really giving our kids independence is so important for them.
[00:40:08] Dr. McBride: Thank you so much for joining me. Thank you for shining a light on American motherhood and giving us a more nuanced view of how it actually is and for bringing data and facts and context to it. So I really appreciate your work and I'm so grateful you joined me.
[00:40:24] Jess: Oh, thank you so much for having me.
[00:40:29] Dr. McBrideThank you all for listening to Beyond the Prescription. Please don’t forget to subscribe, like, download and share the show on apple podcasts, spotify or wherever you find your podcasts. I’d be thrilled if you like this episode to rate and review jt. And if you have a comment or question, please drop us a line at [email protected].
The views expressed on the show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician.
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You can also check out this episode on Spotify!
When Caitlin Murray’s 5-year-old son Callum was diagnosed with leukemia in 2016, her world turned upside down. She started blogging to keep friends and family informed about his treatment, and what began as a medical missive became an outlet for share about life, love, and parenting.
Callum beat cancer, and Caitlin’s star kept rising. As the main character of the wildly popular Big Time Adulting Instagram page and podcast, Caitlin has captured the hearts of parents everywhere with her raw, relatable, and hilarious commentary about raising kids.
On this episode, Caitlin sits down with Dr. McBride to discuss social media for grown-ups; learning to trust your gut; and the heartbreaking hilariousness of being a parent.
So listen, learn, and laugh with Caitlin. She is living proof that humor is healthy.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, review — and enjoy — the show!
Transcript of the podcast is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription," the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts. Our stories live in our bodies.
[00:00:35] I'm here to help people tell their story, to find out, are they okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at https://www.lucymcbride.com/ and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So, let's get into it and go beyond the prescription.
[00:01:03] There are influencer moms on social media with their perfectly curated family life on display, and then there's my guest today, Caitlin Murray. Caitlin created the wildly popular Big Time Adulting Instagram handle and now has a podcast of the same name. It all started as a way of keeping her friends and family abreast of her son's progress as he was treated for childhood leukemia. And it has grown exponentially over time as an outlet for Caitlin to share her thoughts on, as she puts it, life, love, and parenting.
[00:01:37] Caitlin is arguably the funniest and most relatable mom on the internet. Her content is the refreshing antithesis to the Pinterest-perfect family imagery. Her humor makes her audience of stressed-out parents feel seen and heard. It's her authenticity that has made her wildly successful and someone I really admire. Caitlin, thank you so much for joining me today.
[00:01:59] Caitlin: Oh, my goodness. Thank you so much for having me. I'm super flattered to be here with you because we originally met via the Gram and I reached out to you to be on my podcast. And I found you because I was doing a lot of homework on COVID stuff in terms of the risk analysis of masking children in school, which was really something that I was feeling impassioned by at that time. And I was just so pumped to come across such an accredited doctor who spoke really well from both sides about the reality of the situation. And when you said yes that you would come on my podcast, I was like, "Ooh, I gotta tighten my s**t up right now."
[00:02:45] Dr. McBride: Oh, my God. That's hilarious because when you asked me, I'm like, "Oh, I gotta tighten my s**t up right now."
[00:02:50] Caitlin: So, yeah, but I'm psyched to have developed this online relationship with you and see you a little bit in real life via Zoom.
[00:02:59] Dr. McBride: Well, I feel like I know you. And that's, I think, your gift to your audience, is that you let us into your world, you let us into your interiority. And I think what connects to you and me is the fact that neither of us are willing to put up with a lot of BS, whether or not it's because you are a mom of someone who's had cancer, whether you are just born with perspective and wisdom, or whether or not you're just learning as you go like we all are.
[00:03:28] The appeal in my mind of your content is this relatability, authenticity, and humor that allows people who are watching you to feel like we're okay. And that's the title of my newsletter is, "Are You Okay?" I mean, no one's really okay. Which is not to say we're all mentally ill, we're all broken people.
[00:03:46] It's to say that it's on a continuum how we manage our everyday lives, how we manage stress, how we manage mood, how we manage relationships with food, alcohol, our spouses, our children. My goal as a doctor is to help people be a little more okay tomorrow than they are today. And so, when you see someone like you on Instagram who's real and authentic, it's very appealing and refreshing.
[00:04:09] Caitlin: Well, thank you. I really appreciate that that's how you view it because I'm actually a shallow b***h behind the scenes.
[00:04:17] Dr. McBride: Well, I know that. And I'm trying to just cover it up for my audience, but there you go. Like, that's what you are, you're funny and you're real. And I'm gonna guess that you have insecurities like we all do, and you wonder sometimes like, "Wait, maybe I am a shallow b***h." I mean, Instagram is a weird place, right?
[00:04:36] Caitlin: Totally. Yeah. I think it's a place where people second guess themselves constantly just by scrolling along. And it's this over-inundation of information and ideas and stuff that kind of like what you were saying, am I okay, or are we okay? And, like, no, nobody's okay. But that's also okay. Like, that's fine. So, don't overthink it. Just be yourself, right? Because you only get one shot at this whole thing to just be yourself. And what a gift.
[00:05:06] So, starting my page, becoming really vulnerable in a public way is difficult. It was hard to do that at first. And now I am so much more comfortable with it because my audience size has grown and that's validating in itself. So, I feel compelled to continue oversharing all the time. But it's one of those things where when you let your guard down and you make yourself vulnerable, which I try to do, people really can sense that, the realness of what's happening in life and that you're not preoccupied by the b******t. Like, let's just get to the point.
[00:05:45] Dr. McBride: Yeah. And I think social media has allowed people like you to do that because maybe you have an intrinsic confidence or just sense of self that's stronger than others perhaps. But I think there's a lot of fear about revealing our true selves, certainly publicly and even to our own friends and family sometimes or to ourselves.
[00:06:06] There's a hesitancy to really look inside and acknowledge uncomfortable truths, realities about our lives, about who we are, and then Instagram highlights how perfect people are able to present themselves and then it can deepen any preexisting insecurities. So, I think what I'm hearing you say is that the vulnerability you are presenting outward to your audience is also reinforcing to you of the magic of vulnerability for your own self.
[00:06:40] I'm guessing that you're a little bit like me in this way. The glue of my friendships with women in my life is shared vulnerability, and honesty, and truth. It's not a hey, one-upmanship, it's not a competition. It's, like, it's being real. Because first of all, who wants to be around other women who are like, "Oh, I'm so great, and look at my kid, they won this award." I mean, at the same time, my friends are people who can celebrate my wins with me too, and cry with me at the same time.
[00:07:11] Caitlin: But all that stuff is also like, it's frankly super boring when you just talk about what's, like, great, right? Like, I'm like, "Can you tell me what's wrong? Tell me all about your s**t and I'll tell you about mine, right?" So that's what you were saying. Basically, it has been a super validating experience for me and I think that what I hope the followers who are on my page gain is also their own personal sense of validation through seeing somebody let their guard down on social media because it is a difficult place to do that.
[00:07:41] Dr. McBride: Yeah. And giving people permission to explore their own vulnerabilities and be funny, and be silly, and go get a snack. For anybody who's listening who hasn't seen Caitlin's Instagram handle, she cuts through the BS and then often ends her little monologues that are riveting and relevant with, "So, go get a snack," and you tap the camera. And it's just so refreshing. And then I wanna go get a snack and I do.
[00:08:07] Let me ask you a big question. What is your definition of health?
[00:08:11] Caitlin: Yeah, that's a huge question. I feel like it comes from so many areas, but I guess it starts with, self-awareness, so figuring out what is going on in your body, listening to your body and your mind. Because I'm someone who has health anxiety. And I don't know if that's a PTSD thing from what we went through with my son, but I think I've always had a fairly strong element of that within me.
[00:08:39] I think it's just...it had become much more exaggerated for a period of time, and I'm figuring all of that stuff out now too as I go and learning to take the whole picture instead of focusing on something catastrophic or whatever within my body. So, sometimes I feel like I'm too self-aware, I'm paying too much attention to what's going on in my body with that kind of thing. But, you know, just full picture.
[00:09:04] And this is also something I learned along the way with my son, with the doctors that he would see at Memorial Sloan Kettering, which is a world-renowned cancer center and they have fantastic doctors there. And I really praised the way that they were not alarmists and they kept you sort of grounded with things in terms of...maybe a symptom would arise or something like that but look at the big picture.
[00:09:29] Is this worsening? Are there other things going on? Is this something that I need to really fix or should I relax about this and see if it resolves on its own type thing? So, I'm big into movement. I've got to move my body for not just my body but my mind. Like, I've gotta get...shake my crazies out. And then, balance, balance with food, balance with alcohol, balance with getting enough sleep and doing things you like.
[00:09:58] Dr. McBride: It's a great definition. And I 100% agree with you. It has to start with self-awareness. And sometimes awareness brings discomfort when we realize, "Oh, my god. I'm anxious about every symptom." But if you can recognize, as you have, that some of that stems from a real medical vulnerability with a precious person in your life, then perhaps that allows you to forgive yourself for being anxious and also just try to better frame medical issues as they come up. Can you talk for a second about your son and his diagnosis?
[00:10:34] Caitlin: Yeah. He had just turned three years old, this was December of 2016, and I started to notice he wasn't doing well. He had come down with some kind of a virus, like a cold or a flu. It's that time of year. So, I wasn't particularly worried right away. But then he was not bouncing back the way a child should after say a week of illness. And I noticed he was getting more tired.
[00:10:58] He would want to take a nap. He had dropped his nap. His color looked bad to me, his appetite was bad. So, there were all these… a conglomerate of things going on with him. But little kids are not super self-aware of their bodies necessarily. So, they can kind of distract themselves pretty easily. And you might think for a minute, "Oh, maybe he is okay, you know, maybe everything's fine. He's playing right now or he’s coloring." But deep down it was, like, eating away at me. I knew something was going on.
[00:11:30] So, I had taken him to the doctor after, you know, like, the first illness of a couple of fevers and stuff just to make sure everything was okay. And then we went home and then he seemed to have some other illness or the same, just not recovering from. And then he started getting some fevers that weren't going away. And, of course, I visited Dr. Google.
[00:11:48] Dr. McBride: That's not the wrong thing to do. It just can make people more anxious if they're already anxious.
[00:11:53] Caitlin: Totally. But, like, this time Dr. Google was right. You know your child. Like, you know your child better than anyone. So, I took him back and I actually said to the doctor that day that saw him, "This might sound crazy to you, but he's been sick for kind of a while now and I don't see him improving. And he's had this fever going on. I wasn't a big temperature taker, I wasn't really alarmist like that with my kids when they were getting sick. I knew he had a fever because I could feel him being warm. I didn't know what his temperature was every day or something like that. This is maybe day five or six of him being like this. This is crazy, but could he, like, potentially have cancer? He was up all night coughing, all of this stuff.” And I was very quickly sort of, like, brushed off with that.
[00:12:34] I said, "I'd like to see blood work.”... I'll do an exam and if I see any red flags, and then I'll order blood work. So, whatever. The visit goes on and the doctor is like, "You know, I don't see anything totally out of the norm here. He's probably just got, like, a cold on top of a cold or something like that."
[00:12:56] Honestly, 99% of [00:13:00] the time this doctor would've been right, I don't blame her for that. But I knew that he wasn't all right. So, that's just one of those things where you learn to trust your instinct a little bit. And even if you're wrong, who gives a s**t? Just get the blood work done or do what is gonna put your mind at ease because you do know, you know, be the advocate.
[00:13:18] Dr. McBride: I wanna get back to that point after you finish that story because it's such an important moment of the interface between medicine and humans. But go on.
[00:13:28] Caitlin: Yeah. So, then it was Christmas that weekend. This was a Friday, that day that I took him to the doctor. And Monday was, like, sort of Christmas observed, so skeleton-staffed everywhere, that kind of thing. And, like, the last thing you wanna do is go to the doctor on the day after Christmas where it's just, like, exhausted with little kids celebrating the holidays. But I couldn't even get him to, like, take a bite of cake at breakfast that morning.
[00:13:52] I was like, "Do you want some cake?" Because he wasn't eating anything. So, I was kind of desperate for him to eat. And he wouldn't...he didn't want anything. And I picked him up right there and then. I was at my mother-in-law's house, I was like, "We gotta go. Like, I'm going to the doctor right now." And so, we got there and I said, "I just...I don't care. Like, don't bother with testing or whatever, just order the blood work so I can get this. I just need this."
[00:14:16] So, really honestly, two hours later, pretty much we had to drive up to a hospital, get the blood taken and they called back with, like, very alarming results. Some of the markers for leukemia were way high, way low. And we were sent to go to the emergency room at a local children's hospital that day. And that was, you know, the beginning of our cancer diagnosis journey.
[00:14:41] Earth-shattering experience as a parent, just praying so hard that it wasn't what you thought it was and then thinking you might be, like, in a nightmare for a little while. Like, is this really happening to my kid right now? Just putting one foot in front of the other until you got through it because we were really the lucky ones because he's great today he is well.
[00:15:06] Dr. McBride: And how old is he now?
[00:15:08] Caitlin: Now, he's nine.
[00:15:09] Dr. McBride: And he's healthy, cancer-free, in remission?
[00:15:11] Caitlin: Yeah. He had gone through over three years of chemotherapy and other treatments. And that's a standard protocol for this type of pediatric leukemia, acute lymphoblastic leukemia. And he finished it and has been a clean bill of health ever since.
[00:15:31] Dr. McBride: I have lots of, first of all, empathy for what you went through as a parent and as a patient, and as someone who felt dismissed by the medical establishment. I also have an observation that I would imagine that the path you were on for the last six years has helped you with the perspective that you have that you then bring to your audience.
[00:15:54] But first, I just wanna touch on the moment when you're in the doctor's office and you have a maternal instinct about your child and you're not being heard. I think so many people can relate to that moment, whether they're there for themselves or their child, or their elderly parent. There's nothing like a patient's intuition. You know, patients know them more than the doctor knows them.
[00:16:18] At the same time, we see patients who are anxious, patients who go on Dr. Google, patients who come in with a laundry list of diagnoses that they've made on their own. They're like, "I have the flesh-eating bacteria, and I have ALS, and I have Crohn's disease, and just tell me what to do." And we then develop, as any human does, as physicians, we develop biases and we develop confirmation bias so that when we see someone bringing in a laundry list of Dr. Google diagnoses, we think, "Hmm, this person probably is anxious."
[00:16:51] But what's important for any of us, especially in medicine, is to check our biases and to check our egos at the door, and recognize that patients know them better than we know them. And you're right that 99.9% of the time, your son's fatigue and malaise after a viral infection is fatigue and malaise after a viral infection that will then get better with time, but that moment warranted investigation.
[00:17:17] And you weren't the hysterical parent who was checking his temperature 24/7 even when he was going to school every day and healthy. You weren't being hysterical. Even if you were hysterical, sometimes testing is the tincture, sometimes reassurance is the very thing that we can do best for our patients. Sometimes we do tests because we know something's wrong and sometimes we do tests because we know something's not, and we want to honor the patient's natural anxiety and let them dispatch with it.
[00:17:43] So, look, I'm not perfect at that either, but I think it's important for people to recognize that doctors are human too, doctors make mistakes, doctors make assumptions. But this is all the more reason to then be in touch with your intuition and your awareness of your own body and mind and to know what questions to ask, and then also to advocate for yourself because it's very hard to advocate for yourself in the current medical landscape.
[00:18:10] Caitlin: Yeah. That's really the main takeaway that I have gained from my experience with my son, is the self-advocacy or the advocacy of your children. Because as a young mom, you know, my son, that was my oldest. He was three years old and I had a one-year-old at that time too. You don't know that much about kids at that point really. You're still getting to know what it's like to have children, even though that might seem like a long time to a brand new mother of a newborn or something. It's a constant learning experience.
[00:18:46] So, we do put a lot of faith and trust in doctors, which is the right thing to do. Always get a medical professional's opinion. But don't discount your own inner gut feeling. Don't ever not listen to your gut when it feels like you need to ask for more or get an answer for something. Don't be afraid to speak up about that stuff because you'll never regret going the extra mile for yourself or your children to make sure everything's okay.
[00:19:14] Dr. McBride: One hundred percent. And recognize that it's normal to be anxious about yourself not feeling well or your child not feeling well, or noticing something funky. And we need to notice our own reactions to those bodily cues. In other words, there are people who have an outsized level of anxiety to what is a normal physiologic response.
[00:19:36] I had a patient this week come in who her heart rate was 110 when I was measuring her heart rate. And that's an abnormally high heart rate, but it's because she's anxious, it's because she's caring for her elderly mother who's in hospice right now. And so, she was anxious about it being high and I said, "Look, you have a normal heart that's the accelerator that's being pressed and is giving you a fast heart rate because of the fear and anxiety and grief you're experiencing over your mom. So, let's not medicalize your fast heart rate. Let's address the underlying anxiety and grief that you're experiencing." The wrong thing to do would be to treat her fast heart rate with medication. The right thing to do is to acknowledge the reality of her life right now.
[00:20:16] Caitlin: Let me ask you a question about that as a doctor, Lucy, because I always wonder...I do sense that there's sometimes resistance or just lack of interest from medical doctors to look at the mental health aspect of certain...
[00:20:30] Dr. McBride: Oh, man, girlfriend. I mean, why do you think I'm doing this?
[00:20:34] Caitlin: Yeah. But I think it would solve so many problems. I mean...
[00:20:37] Dr. McBride: I mean...
[00:20:38] Caitlin: Stress is the root cause of, like, so many health issues. And I just...I hate that it's never, "Let's try to work on this and see if it helps that," right? Like...
[00:20:50] Dr. McBride: I mean, my job is actually really, really easy. I mean, it requires a medical degree, it requires experience, it requires paying attention and listening. But that's exactly what medicine doesn't have right now, is time to listen to patients. So, if we acknowledge that we all have mental health. You're born with mental health, you can't opt out of the mental health feature of being human like you can a feature on your car.
[00:21:17] So, if you then acknowledge that you have anxiety, that's how we survive in the wild. It's how we get the term paper turned in, it's how we get the Christmas presents wrapped, it's how we get s**t done. We have anxiety, we have moods. We have grief and loss and vulnerabilities. We have relationships with food, we have relationships with alcohol, we have relationships with each other. All of those things we have, that's a given.
[00:21:45] The question isn't do you have anxiety, do you have moods, do you have relationships? It's how do you understand them and how do you gather a kit of tools to manage the inevitable roadblocks that come your way, whether it's a child with a cancer or a mental health diagnosis, whether it's your own health issues which inevitably come up, or whether it is an inherent mental health problem when, for example, anxiety goes from being, "I'm worried about my son's chemotherapy," which is, of course, in proportion to the level of stress, to am I anxious where every time he has a paper cut, I'm panicked that he's gonna bleed out and this is a recurrent tumor?
[00:22:27] In other words, where am I on the continuum of anxiety? Where am I on the continuum of a healthy relationship with food, where I eat when I'm hungry and I don't eat when I'm not hungry? So, it's a long way of saying, yes, if we could just acknowledge that patients are more than a bag of organs and they are humans, they're dynamic and that our stories live in our bodies, medicine would actually be serving people.
[00:22:58] Caitlin: Yeah. And like you said, every case is nuanced. One patient is not going to respond the same way to the same treatment as another patient necessarily. It can be trial and error or not one size fits all, basically.
[00:23:17] Dr. McBride: One hundred percent. And then let's take it a step further. When you get dismissed by a doctor like you were, when patients every day are being not heard in the doctor's office and medicine has become a cattle-herd style, cookie-cutter style exercise, and we define health as the sum total of your lab tests, what happens to patients? They don't trust doctors. They don't trust that they're being seen, and they're not.
[00:23:44] So, what do they do? They go on the internet, they go on Dr. Google. They look for wellness memes, they look for quick fixes, they look for cleanses, they look for diets, they look for candles and funky stuff. Look, I love candles. I buy crap that's in a pretty package, but I have my expectations managed of what it's gonna do for me. I bought this, like, body lotion at CVS the other day and it was, like, lavender scented it said calming lotion. And I'm like, "If this lotion… can calm for $2.99, that would be amazing." But here's what the wellness industry does, and it's well intended in many ways, is that it actually mismanages people's expectations and it steers people away from the exercise of looking at the hard truths of their lives in many cases. And it's exactly why your content is popular, is because people are not being heard, they're not being seen, and then they go on Instagram, they're looking for that quick-fix-cure fitness instructor and then they find Caitlin, and then they're like, "Ugh, thank god. I'm gonna go have a snack."
[00:24:47] Caitlin: Well, thank you. I think what you said there too, it's like when you said the word the wellness industry, it is an industry. And that's also part of, like, social media industry and buying and selling, and what you're made to think or believe based on a market, and learning how to discern what's actually happening versus what you might be over-perceiving to be happening, or what is really right versus what somebody said was right, or something like that, just listening to yourself.
[00:25:20] Dr. McBride: So, Caitlin, you and I met on Instagram because I immediately was attracted to your vibe, and also because you were advocating for common sense policies when it came to COVID mitigations in kids. You're a mom of a child with an immune-suppressed condition, yet you also were able to see what I see, which is health is about more than the absence of COVID-19. Can you talk about that just a bit?
[00:25:46] Caitlin: My son, you know, he was an immunocompromised child when this pandemic began. And we had, you know, firsthand information from how children...and particularly children on the oncology floor at Memorial Sloan Kettering at the beginning of all of this, real-time information about how those vulnerable kids were faring against COVID. And our doctors were very much, "Don't be worried about this in that way." They were consoling us, genuinely frightened parents of our immunocompromised children that this isn't something that we're seeing having very serious outcomes with children at all. Thank God.
[00:26:27] Dr. McBride: Absolutely. So, I'm really curious, as a content creator yourself, what is it like sort of internally to be putting yourself out there, talking about yourself, like, giving pieces of yourself to other people? What are the biggest upsides and what are the biggest downsides to that?
[00:26:46] Caitlin: The upside is it's a fantastic creative outlet for me. Like, it really fills my cup. I like doing that stuff. I like delivering it in a humorous way. I get a real [bleep] kick out of myself.
[00:27:01] Dr. McBride: I hope you do because I would imagine that you have fun just hanging out with yourself.
[00:27:04] Caitlin: Oh, no. I mean, you know what? Part of this is, like, the isolation of motherhood being home with little kids because I was really locked up with my kids for so long, my little kids. And they are boring sometimes, you know? Like, they're busy and there's so much action, but not a lot of, like, adult mental stimulation.
[00:27:22] So, it was like I was talking to a bunch of people all day. So, that was really fun for me. And I love that. But then there are, you know, moments where I do feel like, "Oh, man, I just said that today about this and that's my kid's teacher who probably saw it," you know? So, within, like, you're in a real-life community, you can be a little bit like, "Oh, god, that person probably saw me shaking my ass in the kitchen this morning, whatever."
[00:27:54] Not that I really care because I don't. Because you can't if you're trying to, you know, build a real authentic brand, audience, community, you have to just sort of put it all out there. But then I also do think about, as my kids get older and more aware and are maybe on social media at some point in the coming years, what they will think, if they will be mad that I've been making fun of them so much, or what.
[00:28:28] But honestly, again, it comes back to just being authentically who I am and kind of staying true to myself and doing what I really feel, like, compelled to do personally because I don't know, for whatever reason, I really want to do what I'm doing here. And it's about following sort of my own goals and dreams in that sense. And I hope that the way that I explain it to my kids, I'm really honest with them and stuff, that they will also respect that. So, upsides are super personally fulfilling, and downsides is maybe, in real-life, community perception of you. But you have to just sorta roll with that, take it on the chin.
[00:29:06] Dr. McBride: For anybody who's not following Caitlin yet, when you say, Caitlin, that you're making fun of your kids, it's so clear the deep love for your children that you have. Because as we both know, there are a lot of people on Instagram talking about early motherhood is the best time of their lives, and, "Look at my child with this perfect outfit."
[00:29:26] And anyone who's been a mother knows that those early years are particularly hard and, like, not pretty in so many ways. And so, you're giving people permission to acknowledge that. And it's obvious that you love your kids beyond words. It's obvious. So, you can then make fun of them and make... There's no mean-spiritedness about it. I'd love you to give some examples of what diddies have you done lately that gave you the most kicks. Because I'll tell you the ones that I like the most, but go ahead.
[00:29:55] Caitlin: I'm fairly known for just going right out there and calling toddlers a bunch of a******s because they are.
[00:30:01] Dr. McBride: It's perfect. It lands so well. How are toddlers a******s?
[00:30:04] Caitlin: They're so ego-centric, which is by no fault of their own, their little underdeveloped frontal lobes. And they only care about themselves, they don't care about you. They care about what they want when they want it and they make everybody miserable until they get it.
[00:30:19] Dr. McBride: And then tell me about, like, the most fun diddies you've done where... Like, one of my personal favorites is when you're...I mean, you dance a lot but when you're in the...I think it's one of your most popular...it's one of your most viewed where you're in your kitchen and you're dancing with a broomstick and your son kind of, like, pads up to you and, grabs something that you have.
[00:30:49] Caitlin: Dance ones are like... There's a whole portion of the audience that, like, loves the dancing. And then I think there's a whole portion of the audience who is just there for the jokes or the stories. I think, like, the stories are pretty popular because that's really where you get, I think more of the real me if you follow along. Because the grid, my grid is more, it's jokes or dancing or something. It's, like, the hook and then you stay for the real in the stories, I'd say.
[00:31:08] Dr. McBride: And so, what do people respond to the most? What do people write back, and what do people say to you?
[00:31:13] Caitlin: I mean, so many DMs about, like, just conversations that I have in my stories. I mean, I did kind of a botched silly makeup tutorial...not a tutorial, just so many people had just asked me like, "How do you put your makeup on?" And so...
[00:31:31] Dr. McBride: Oh, my god. You know you've hit the big time when people are asking you what your makeup routine is.
[00:31:36] Caitlin: I'm, like, also hardly ever wearing makeup on my Instagram page, so it just made me chuckle. But then, like, people have their suggestions about, like, what you should or shouldn't do with your face or whatever and I'm kind of like, "I'll [bleep] decide what I wanna do with my face." You know, like, I wasn't asking for advice. But I think people respond to the story. I think that's why people...like, where they feel the real connection to me is via my Instagram stories because that's really where I am a real person. Because the page, the profile grid is more theatrical and the joke being delivered or dance or something.
[00:32:15] Dr. McBride: Where are you going with this? What is your...? Do you have a plan or are you just sort of taking it one day at a time, or do you have sort of, like, big aspirations for Big Time Adulting?
[00:32:24] Caitlin: I do have big aspirations if I'm being totally honest.
[00:32:28] Dr. McBride: Be honest.
[00:32:28] Caitlin: I'm playing the long game with all of this. So, it was never, "I want to jump into this and become an influencer." That was never a goal for me. I want to be able to monetize what I'm doing, but in a more meaningful way, I guess, so via real content that I've created or partnerships, and those sorts of things. Because I have sort of waited and waited and waited, and not accepted some sort of opportunities that I didn't feel like were really true to me or authentic for me.
[00:32:59] I'm starting to see some doors opening right now that are really exciting opportunities that I'm hopefully going to be getting involved in. And it's been just kind of being patient and waiting to see what opportunities sort of naturally come into my life via this platform. I will probably, maybe soon, do some sponsorship, something with a brand that is truly a brand that I like and use. And I will always probably have, you know, a give back to pediatric cancer research and stuff, which I feel like is just...it's a motivational thing for me too. I'm like, "Yes, I can make money and I can also give back as I'm making money."
[00:33:43] Dr. McBride: I mean, during your son's treatment, I think you started a Cycle for Survival team.
[00:33:46] Caitlin: Yeah. We've been doing it since 2017 and we've raised, like, over $0.25 million through our team. We've become really invested in the organization because it gives specifically to rare cancers. And all pediatric cancers are rare. So, it's just phenomenal in terms of a research-driven program because 100% of every dollar raised goes to research.
[00:34:11] Dr. McBride: That's incredible. And it's another example of how you're using your content for good. I mean, you're reaching people as individuals in their kitchens and you're also reaching a wide audience. You're also helping childhood cancer with this work. That's amazing.
[00:34:28] Caitlin: Yeah. I feel, you know, it's gonna be something that will be part of my life forever now. So, I'm committed to always giving back.
[00:34:48] Dr. McBride: So, when I asked you the question, what does it mean to be healthy or what's your definition of health, you immediately said self-awareness. So, I would argue that it's that self-awareness for all of us and then it's a laddering up from awareness to acceptance of things we can't control, and then agency. So agency and feeling like you have meaning, purpose, and the ability to affect change in your life or in others' lives is part of being healthy.
[00:35:07] And that's what you're doing because you've taken a vulnerable moment in your life like being a parent of a child with cancer, where you have very little agency, to creating a platform where you are forced to be more self-aware than ever, accept things you can't control like what other people think of you, and then now you have these opportunities and you're making a change in the world for childhood cancers en masse.
[00:35:30] I mean, the world is your oyster. I don't mean to be hyperbolic. I tend to, pedal in hyperbole, my kids accuse me of that. I'm so excited to see where you go with this because you have all those ingredients. You have the self-awareness, you have the acceptance, and you have agency. Obviously, you're a work in progress like the rest of us, but it's gonna be fun to see what you do with this.
[00:35:50] Caitlin: That's so kind of you. I really appreciate that. I mean, I'm really flattered when I hear anyone say something like that. And it's been a really fun journey. And having an opportunity like this just to, like, chat with you and kind of think deeper into those topics of health and things that are really important. So, who wouldn't like to spend, you know, an hour and change of their day doing that?
[00:36:16] Dr. McBride: It's great. And social media has so many warts, but the upside of it is the connection that's real and authentic. And that's what's fun about it for me.
[00:36:25] Caitlin: Yeah. I never would've imagined that would be real. It would be like people that you speak to online, that sounds really creepy, you know? But it's so true. You really do feel like you've come to...I mean, and we've obviously had real conversations before, come to know someone via online.
[00:36:45] Dr. McBride: It's possible and it's a very cool feature. If you can abandon the BS that comes along with it and just lean into the fun part and the connection part, it's a really amazing place.
[00:36:56] Caitlin: It is. I'm grateful for it.
[00:36:58] Dr. McBride: Caitlin, thank you so much for joining me today and for sharing part of your life, and yourself, and for reminding us what it means to be human.
[00:37:06] Caitlin: Oh, my goodness. Thank you, again, so much for having me. Such a pleasure getting to know you and chatting.
[00:37:14] Dr. McBride: Thank you for listening to "Beyond the Prescription." Please don't forget to like, subscribe, share, download, and rate the show wherever you find your podcasts. And if you have a comment or question, please feel free to drop me a line at lucymcbride.substack.com.
[00:37:31] Our theme song is courtesy of my brother, the multi-talented, Walter Martin. Thanks, Walt. You can sign up for my free weekly newsletter about mental and physical health at lucymcbride.substack.com. The views expressed on the show are entirely my own and do not reflect the views of my employer and should not be a substitute for advice from your personal physician. "Beyond the Prescription" is produced at Podville Media in Washington, DC. Until next time, be well.
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You can also check out this episode on Spotify!
In honor of Mental Health Awareness month, we welcome Dr. Samatha Boardman. Dr. Boardman is a New York based positive psychiatrist who is committed to fixing what’s wrong and building what’s strong. She writes the popular newsletter called The Dose and is the author of Everyday Vitality, a book about leaning into our strengths to bring about positive change.
Historically, psychiatry has focused on the diagnosis of disease and the treatment of individuals with mental illness. Positive Psychiatry takes a more expansive approach, focusing on the promotion of wellbeing and the creation of health.
Dr. Boardman is passionate about cultivating vitality, boosting resilience, and transforming full days into more fulfilling days. Today Dr. Boardman sits down with Dr. McBride to discuss finding wellness within illness, strength within stress, and how to live with anxiety rather than being defined by it. Dr. Boardman is here to help!
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, review — and enjoy — the show!
The full transcript of the show is here!
[00:00:00] Dr. McBride: Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is Beyond the Prescription, the show where I talk with my guests like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight, that we are the integrated sum of complex parts.
[00:00:33] Our stories live in our bodies. I'm here to help people tell their story to find out whether they are okay, and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter through my website at lucymcbride.com and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
[00:01:01] Today's podcast guest is Dr. Samantha Boardman. Samantha is a positive psychiatrist, a clinical assistant professor at the Weill Cornell Medical College in New York, and the author of a book called Everyday Vitality. It's a book that combines her research as a clinical psychiatrist in New York to help readers find strength within their stress.
[00:01:24] I met Dr. Boardman through a mutual friend. I started reading her book and listening to her talk on Instagram, and it was clear that we had a common interest in helping people marry mental and physical health. Today on the podcast, we will talk about when is therapy not appropriate? We'll talk about medication, we'll talk about Zoom versus in-person therapy, and we'll talk about leaning into our strengths as opposed to focusing on the negatives. Welcome to the podcast, Samantha. I'm so happy to have you.
[00:01:53] Dr. Boardman: Thank you so much. Thank you for having me. I'm a huge fan.
[00:01:57] Dr. McBride: So today, Samantha, I'd love to talk to you about many things. One is your definition of health. What does it mean to be healthy? So let's just start there.
[00:02:07] Dr. Boardman: Great place to start. And so I think my definition of health has really changed over the past 20 years. Like you, I went to medical school and then I did a psychiatry residency. The definition of health for me then was the absence of illness. And what I thought of myself as doing my role was to make people less miserable as a psychiatrist.
[00:02:30] And I've gotta tell you, I got pretty good at misery along the way. But one day I was actually fired by a patient who said, when I come to see you, we just focus on what's wrong with me. We don’t really focus on what's going on, what's wrong with what's going on in my life?
[00:02:47] And she was right. I was so fixated on symptoms and dialing down the issues, dealing with conflicts in her life and that type of thing, and less focused on what makes life meaningful for her, what she enjoys doing and where she finds purpose. It sort of woke me up and I ended up going back to study applied positive psychology, which was sort of the opposite of everything I had learned in medical school, in psychiatry residency.
[00:03:14] I studied optimism. I studied resilience. I studied post-traumatic growth. All these data-driven experiences that were really absent in my education and so much that had been focused on pathogenesis, which is the study and understanding of illness in switching over more to salutogenesis, which is the creation of health.
[00:03:36] So this is a really long-winded way of saying, I think of health as so much more than the absence of illness, and I'm deeply interested in how we can help people create wellness within their illness and strength within their stress, and add vitality even into their very busy lives. And as you know, when we ask patients, what's most meaningful to you?
[00:03:57] What do you care most about with your mental health? Or your health in general? People say, I want to have a good day. I want to feel energetic. I want to feel strong. I want to be able to give back. I want to spend time with friends and family and those types of things, that's what salutogenesis is—creating experiences of health and joy and meaning and vitality and energy for them in their everyday lives.
[00:04:24] Dr. McBride: It's so important because just like you discovered along the path of your training and clinical work, I too realized that my job isn't just about helping people not die. It's about helping people live. And it's not enough to tell people at their annual physical, “Hey, your labs look fine. Get a little more exercise, eat a little healthier, and I'll see you next year.” Not dying is good. But what about living? What about having agency over our everyday lives the 364 days a year that you're not in the doctor's office? And what has always struck me since I was a pup of a medical student is that self-awareness is like ground zero for our health.
[00:05:14] When we are able to pull the curtain back on who we are as people to understand not just our genetics, but really our stories and how our stories inform how we feel—literally our body parts—and then how we organize our everyday behaviors and thoughts around the narrative that we tell ourselves, and that's really why I became in interested in mental health and why I find your work so compelling is because I think we're having a moment in our culture where mental health is more acceptable to talk about; where people are more empathetic about mental illness.
[00:05:55] I still think we don't have a great understanding of what mental health is. And to begin with that we all have it. And I wonder what you think about this concept of everyone having mental health and it's just on a continuum versus mental health versus mental illness. And then secondly, to what extent do you think just mere self-awareness is an important ingredient in having mental health?
[00:06:25] Dr. Boardman: Both [of those are] awesome questions and I think that kind of you have it or you don't is this binary, and really limits us about either you're mentally healthy or you're not. And I think that's sort of the way I was trained. Not to be critical of my training, but that was either: you need to be hospitalized or you don't, you're ready for discharge… and not kind of looking at all of those other factors that you look so closely at.
[00:06:51] They kind of give you and provide for you even this scaffolding around you to help you make better choices, to have more better actual days in your week. And this idea that how do you find wellness within illness? And it's something Dr. Ellen Sachs was the one who first I heard speak about this and she was a graduate student.
[00:07:13] I think she was at Yale where she had her first psychotic break and she was diagnosed while she was a student there as having schizophrenia and having a psychotic illness, and her parents were told at the time that they should remove all the stress from her life, that she should withdraw from school, that it was too much for her to bear and that, you know, that maybe she could get some very simple job somewhere.
[00:07:38] Maybe she could pump gas. She could do something that was not going to strain her or stress her in any way, and that most likely she should be hospitalized over again and again, and she might end up rocking back and forth in some institution watching television on lots of medication and drooling.
[00:07:54] And she said her parents understood this diagnosis, but they refused to accept this prognosis. And she had support, she had resources. She went back to school. She had psychiatrists, she had therapists. She, I mean, she was, she was supported by so many buoys around her and scaffolding.
[00:08:15] She returns to school, she finishes at Yale. She then goes on to Oxford where she gets a degree as a champion of mental health law. She goes on to win a MacArthur Genius Grant. She's an extraordinary woman and defies how people like me are trained into sort of expect that runway of what schizophrenia can do to a human being.
[00:08:36] And you know, and she says that actually having this meaningful work in her life has really been, is what saved her. When her voices get loud, she uses her legal training to say, what evidence do you have for that? And how having a really strong sort of sense of purpose in her life has really saved her.
[00:08:55] So when psychiatrists like me say, take all the stress out of your life. Remove anything difficult. How do we find that balance for people of helping them lead that kind of meaningful life in finding wellness within their illness, and even for those who don't have a diagnosable condition… [finding] some strength within their stress so they can live with it.
[00:09:18] It's not being able to… I think we've all learned about Winston Churchill, who had that black dog of depression, but learning to live with it rather than trying to sweep it under the rug or be in denial about it. Or completely defined by this. And we know even with the language we use when you call somebody a schizophrenic versus somebody who has schizophrenia, not only does it change the way that the person thinks about themselves, but it also changes the way that the people who work with them think about them.
[00:09:47] If that is part of their identity, that's who they are versus that something they live with. And it comes and it goes. And there's interesting, Jess Day has done some really interesting research on schizophrenia looking at how a significant number find happiness, find meaning, and it's those who have some of these more lifestyle factors available to them that do make them more resilient.
[00:10:09] Dr. McBride: It's a really good point. You wouldn't be surprised to hear, I had a patient who exhibited all the symptoms of depression. Fatigue, sort of that psychomotor fatigue, that sort of hopelessness joylessness, and then was gaining weight. And we didn't have another diagnosis because we had done all the tests, we'd done the scans and everything was normal.
[00:10:28] And I said, “do you think it's possible that you're depressed?” And she looked at me and said, “what do I have to be depressed about?” And I thought, gosh, this is such an interesting thing. This is someone who unfortunately is a victim of this concept that you're either mentally healthy or you're mentally not.
[00:10:46] When we all have moods, it's a continuum, and my question to patients isn't, do you have an ICD 10 code of F 32.9? My question is, where are you on the continuum of mood and what tools do you have to manage them? What symptoms are you having and what tools do you have? Because it's not about are you mentally healthy? Are you mentally well? And it's not about, are you happy all the time and joyful and gleeful and skipping through the streets, or lying in bed or standing on the edge of a cliff about to jump. It's where are you located on the continuum of these universal conditions of having moods, having fears, having anxieties.
[00:11:26] And so I said to her, it's really not about a thing, it's about what's happening to your body and mind right now. And I don't need to name it. I don't even need a code or a label for it. I just want to understand if this is an organic depressive phenomenon, what agency we can carve out to help you feel better in your everyday life.
[00:11:47] Dr. Boardman: That interesting point that you're making too, that she's feeling guilty about, what do I have that… that question your patient asks, what do I have to be depressed about? And that's something I hear a lot in people who think, “I'm so lucky. How on earth, how dare I be in this state of mind? It’s shameful.” And I think this sort of goes hand in hand with some of this toxic positivity we hear all the time as well. You have to be happy all the time. You have to not have stress, you have to sort of have that sort of fan wind blown hair and that everything has to be perfect or there's something really wrong with you.
[00:12:24] And what you're pointing out too is this notion of over the course of a day, over the course of a week, over the course of a minute, how our emotions can shift and it's calling into question, this idea of your personality type, you're just a grump and all those different things.
[00:12:42] Maybe I'm a grump right now because I just got a parking ticket. But if I actually filled out some of those forms testing my personality an hour or two later, I would probably be in a better mood. All of these, we have so much emodiversity in our days and how things come and go and actually there's evidence to show that people who honor and are able to acknowledge their emodiversity…we have this like binary idea that either people are good or you're bad. You had a good day, or you had a bad day, you're happy or you're sad. Anything that really kind of limits the way we think about our own mental health. It's even the way we think about our loved one's mental health, trying to tease apart the nuance and appreciate the emodiversity that we're handing, like enjoying the laughter through tears.
[00:13:28] How we can hold emotions side by side. It's not that either or situation. And the other side of this is this kind of wellbeing industrial complex that is: feeding off of toxic positivity too, this idea that we need to really make these radical changes and transform every single thing we do. Like: we should move neighborhoods. We need to go on vacation for six months. We need to buy this candle or this bubble bath, or this new exercise bike, or all of these wildly expensive and time consuming endeavors that we are kind of constantly told are the only way that the clouds will part and that we will be able to be happier.
[00:14:15] And I think that it really frustrates me and it's sort of like a pet peeve as you can tell. I'm getting sort of animated and annoyed by it. But this, this idea that you have to buy it and consume it and carve out all this time for it and that we're kind of missing a lot of these everyday actions that we can take that boost our everyday wellbeing.
[00:14:34] Dr. McBride: So let's talk about that. I'm assuming that in your practice you see patients who are experiencing relationship stress, who are experiencing anxiety symptoms, who are having insomnia, who are dealing with substance abuse issues, who are depressed. Obviously you can't speak to every person you see, but what are some common themes that you see in patients where they have more agency than they think they do?
[00:15:04] They may think if they just had a different job, everything would be okay, or if they could just take a six month vacation, they'd be okay. Or if they didn't have the mother that they had, they would be okay. And I think what I'm hearing you say is that sometimes radical changes are necessary. Certainly if you're in an abusive relationship or if you're addicted to alcohol, change is appropriate, external change. But sometimes it's a mindset and it's an internal change. And so what are the sort of simple tools that you commonly dispense to your patients?
[00:15:37] Dr. Boardman: Well like you're describing, I think these people sort of living in this as soon as space in their head, like as soon as I get this project done, I'm going to start working out. Or like as soon as I deal with this thing with my kid, then I'm going to… And that as soon as can kind of create this, we end up inhabiting this kind of liminal space where this penumbra of just kind of flailing and not really embodying and I, you and I, I think, share this belief in embodied health, kind of actually doing as you say, and acting as you do… wanting to kind of have your intentions align with your actions and I've been really interested in that research of how do you kind of close that intention-action gap. Like we, how do you get from where you are to where you would like to be? And that's such a, I think a common experience for all of us. I just consumed a huge bag of Cadbury mini eggs, like I didn't want to, but there they were.
[00:16:38] And there's a limited edition. So that's just the way that it is. But those intentions that we have don't always translate. And so identifying what is the barrier between you and actually the action that you wanna take. And Gabriele Oettingen, who's at NYU, she's been doing a lot of research on mental contrasting, this idea of figuring out what your reality is versus what your hopes are. And as much as maybe it's an American thing, that whole idea of like dream big, think positive, you know, you can manifest your dreams. You wanna manifest that you have lost 20 pounds, or that you're going to the gym all the time.
[00:17:21] All of this actually really doesn't help us. And it might feel good at the moment when we're sort of thinking positive, but it really doesn't translate into action usually, and typically, it makes us feel worse when our reality, when we bump up against our reality in some way. And so how do you close that?
[00:17:42] And so her research shows with mental contrasting—she calls it using this acronym of WOOP, W-O-O-P. And this is an exercise I think all of your listeners can do, and it, it, it really works. And they've seen it with weight loss, with saving money, with exercise, in relationships, all these different domains where WOOP translates into actionable change because as we know, it's quite hard to sustain change.
[00:18:07] We can get somebody to stop smoking for a day, but. A week later, they'll probably go back to it. So here's what whoop is. The W stands for like what is your wish? It has to be something that's intrinsic to you. It's not that something your partner wants you to do, something you care about deeply that aligns with your values. Make it as specific as you can. Like my wish is I would use my phone less when I'm with my kids or whatever that thing is. And then the O stands for, okay, what would be the outcome of that? Like really think about what that outcome would be. I'd feel more connected. I'd feel less pulled in a thousand directions. I'd feel more present. What would that outcome be? And kind of feel it. Literally feel it. And then the next O is, okay, what is the obstacle? You've got to identify the obstacle. Okay. Well, it's always in my hand. Whenever I pick them up from school or whenever I'm sitting at home, it's always next to me. If I'm cooking or at the table, it's always there.
[00:19:04] Okay, so you've got your wish, you've got your outcome, you've got your obstacle. The fourth part is what is your plan? How are you gonna deal with this? Okay, I'm going to turn it off when I'm at home, when we're all together, I'm not going to have my phone at the dinner table. Knowing that wish, but also understanding what is getting in the way of that thing, that obstacle and then having a plan around it is much more likely to produce actionable change. And she's shown this in over 35 papers and, and just really shown the positive outcome of doing that. So just thinking positive, it's not gonna get you anywhere. But actually kind of having, contrasting that, thinking positive with that plan and that identification of the obstacle will.
[00:19:47] Dr. McBride: I think that's so important. I think what people don't like doing, myself included, is turning the mirror on themselves and looking at hard truths about themselves that they maybe go on their phone because it sort of quiets the noisy brain, or it's sort of a distraction from all the messiness in our internal world, and we haven't thought through what the consequences are, and we think we'll do better in the next day.
[00:20:15] And so we do much better liking an Instagram meme that says, think positive than we do at actually looking at our interior and making changes. So like you, I'm particularly interested in that gap between our best intentions and the execution of them, because that's really the most interesting part of my job and the hardest part of my job is helping people start an exercise program, put down the cigarettes, lose the weight they need to lose for their diabetes. And a question I have for you is, because to me a lot of the gap is about self-awareness and sometimes mental health, but not mental illness necessarily. Mental health being defined as really an awareness of our moods, our anxieties, and how are they calibrated to the actual facts in our reality.
[00:21:11] And my question is then, how often do you find people not being aware of their own sort of internal barriers? How common is denial and an absence of self-awareness and an absence of wanting to look at people's stories the problem as you try to affect change?
[00:21:34] Dr. Boardman: I mean, I think we're all in denial.
[00:21:36] Dr. McBride: Yeah, I think we are. I think it's convenient.
[00:21:38] Dr. Boardman: Yeah and it serves us really well in the short term. And we're not even meaning, I mean, denial is sort of an unfair way to put it. I think we're trying to live in a different reality than what we're in, or we tell ourselves stories as you know, like, well tomorrow I'll do it, or, today it's somebody's birthday or whatever. There's so many justifications in the moment, but it is at the same time, I think that gap between our intentions and our actions is an annoying feeling. It's what kind of keeps us up at night. Why didn't I? It's a lot of regret and beating oneself up.
[00:22:12] Even though maybe we're going through the day putting out lots of fires, I do think there's that lingering sense of, especially in the evening, or especially if you can't sleep at night, of why didn't I, why did I do this? And that sense of when we're not aligning our values with our actions, and it's something that I actually ask patients to do when I first meet them, as in, it's part of that kind of self-awareness tool I think you're describing is to write down or just to think about what are three to five things that you value most.
[00:22:47] What matters? What do you care about deeply, what is most meaningful to you? And oftentimes, we're all such busy people, [so we] don't take the time to figure out what those things actually are. And it might be being a good grandparent. It might be taking care of my dog. It might be my health, it might be learning something, whatever that is.
[00:23:09] And then I ask them to think about when you last, on Saturday or when you had some free time, how did you spend it? And really trying to kind of break down how they spend their time and how that aligns with what they value most. And ideally trying to create as much overlap as possible between the two.
[00:23:32] Because I think when there is this disconnect, even when things don't go the way we hope, that at least I think when you feel like you're embodying those values and they're manifesting in your life, even when things aren't going your way, it kind of creates a bit of an armor around you because you actually feel that you're embodying what you care about most, even if it didn't work out for you.
[00:23:53] The other thing is just to remind people, I think we often feel like a failure. [In terms of] I made this commitment, I was going to go to the gym every day this week, and Wednesday just got so busy or whatever. I'm a failure. I'm not gonna start till next week. This idea that every day is an opportunity for a fresh start, even this idea that, oh, I have to wait until this landmark in time… I'm gonna wait till New Year's to stop smoking…
[00:24:18] Tomorrow's a new day, and I think you can kind of just try to harness that fresh start effect at any point. We know typically that people who went, who do, and this is Katy Milkman’s research, if you do it on a Monday or you do it on your birthday, or you do it the first day of the month, you might have more momentum behind you, which is great, but you know, I also think that every day is a new opportunity, rather than thinking, oh, I just gotta throw this all out. You know what? I'm just gonna have a crazy binge eating weekend and just let it all go, versus, you know what? Tomorrow's a new day. And we're really good at beating ourselves up over the stuff that we didn't do well.
[00:24:52] Dr. McBride: Yeah, I mean, I think so many patients that I see who are having a hard time losing weight, exercising more, eating healthy, whatever it is, they lead with a heavy sense of shame and fear in their lives and I'm interested always in pulling back the curtain to figure out what is driving those feelings. Sometimes it's just not doing what they know they should be doing. Sometimes it's pretty simple. It's like, well, I wanna lose weight, but I ate a plate of cookies, so I feel bad about myself. But I think you might agree that there's something deeper going on, and maybe there isn't. I'm not trying to say that everyone's experienced childhood trauma and that pops up at the minute they look at the cookies and they feel bad about that experience and then they binge eat.
[00:25:33] I just think that there's, there's something about our stories and our childhoods and our past that holds us back from being honest about ourselves and overlapping, as you said, the intention with the execution and living that sort of authentic life that we wanna lead.
[00:25:56] And I wish we had an injection for pulling the walls down of shame. If we could take shame and fear away, we would be… we don't want to take away too much fear, otherwise we'd be walking into traffic and we'd jump off of high dives without water in the pool. We need a little bit of fear and we probably need a little shame too, otherwise we'd be sociopaths. But so many people that I see who are trying to make changes in their lives and live authentically, adhere to the rubric of whatever the meme on Instagram said. They can't execute on their best intentions because they are so ashamed of who they are and the stories they tell themselves.
[00:26:36] And that's when I send them to you. That's when I send them to a psychiatrist. Not because they're crazy, but because they're human. And I say, look, I literally say those words and I don't think you're mentally ill. I just want to help mine that space. I could just tell you to do better tomorrow, and I could tell you that you're okay. But I, I think there's something there that I think… I just wish we all had more of a permission to explore those parts of ourselves.
[00:27:01] Dr. Boardman: As a psychiatrist, maybe this is weird to say, but sometimes I think we don't need to always be looking under the hood. Maybe just to push back a little bit on this, that there isn't always an explanation… like my mother did this, or whatever that thing is, or this is my comfort food and that's why I do this now, and it is wonderful. I think when you have those light bulb moments, you know that you have this idea of, oh, this is why I do that. But here's the thing. I mean, research shows that it doesn't necessarily translate into behavior change. You might be like, oh, this is why I do that but you're not, you're still not going to make any meaningful, or take any meaningful steps to stop that thing.
[00:27:47] It's kind of a cool thing, but it's not necessarily transformative. And so one thing that I'm deeply interested in is this mode of therapy called behavior activation that is really asking people rather than to focus on their emotions or always kind of trying to excavate the past in some way is to just focus on the change, the actual behavior, and then see how that changes the way they feel.
[00:28:18] Because I think so much of psychiatry is the whole idea of if you can change how you think and you can change your emotions and your relationship to them, then that's going to change your behavior. And behavior activation kind of flips that on its head and says, oh, if you change what you do, you're going to change the way you feel. And we know that to be the case. If you ask people to, for 30 minutes a day, four days a week walk on a treadmill slowly, it immediately changes their mood. We know that going outdoors, you get this transformation. Even if you're sitting and you're kind of hunched over and then you stand up and you put your shoulders back, you actually feel differently
[00:29:00] That idea again of embodied health, what you do changes how you feel, as much as how you feel changes what you do. And I think in psychiatry and therapy, we've been so focused on one side of it and not looking at that kind of more embodied health of the behaviors that are going to impact what you do because we often get wrong a lot of stuff. We think the thing that's gonna make us feel better is not. Like, oh, I had a long day. I'm going to binge watch tv. I'm going to open up my favorite bucket of ice cream and that kind of short term emotional junk food or actual junk food that we indulge in.
[00:29:37] But we all know that we had to, the first bite's good, the next one, not so much, you end up feeling worse about these types of things. And they are de-vitalizing, I think of them as like a vampire, as a vitality. And the stuff that makes us feel better is actually when we're learning something, we're actually not just engaging in efforts, sparing activities, we're actually doing something that stretches our minds or stretches our bodies in some way. That's, that's kind of engaging us in some meaningful way. And so, I guess I'm a big fan of doing, not dreaming in some way and engaging and acting and seeing how that makes you feel. And this is research out of Stanford that looks at behaviors and what creates behaviors, it's either motivation. That is something we focus on probably way too much. And it's either a trigger, like you see somebody light up a cigarette and you're like, oh, I want one too. Or it's accessibility, how easy is that behavior? And I think an underrated part of this kind of equation is accessibility and making it easier for people to do the behavior that they want.
[00:30:48] Because when we're so focused on motivation, self-control and self-control as we know it comes and it goes. You have it in the morning, you have the best intentions by the afternoon. Somebody puts a plate of cookies in the conference room. You can't help yourself. But if you make it a little bit harder to do that behavior that you don't want to do, like you get rid of those M & M’s or you you make it a little easier because you put your sneakers out in front of your bed the night before and you make, so the behavior you want to do easier and the behaviors you don't want to do harder.
[00:31:21] And this comes from even a community system standpoint, you create accessible parks, you have lighting, so it's easier for people to walk outdoors. You create attractive staircases for people to be able to use in buildings, all those types of things to make it a little bit more fun and easier and more playful to engage in better behaviors. So I think about, how do I make the behavior that I want to do easier, [and] how do I make the behavior that I don't want to do harder?
[00:31:49] Dr. McBride: I love it and I love the pushback. I mean, I love anybody who has an opinion. And I also love anybody who is challenging the popular narrative out there because I think the popular narrative is, and I do subscribe to it in many ways, that excavating our interior is a way to begin that laddering up of health and wellbeing, that understanding our stories can help us make the behavioral change we want to make. But I think you're right, and I see this in patients. Therapy is not a good idea for everybody. It's not necessary and it's not sometimes helpful. It sometimes does harm. And what I mean by that is that, first of all, there are some pretty terrible therapists out there. There's some pretty terrible doctors out there too, and I'm sure I'm terrible on some days of the week.
[00:32:40] But also I think that the talking, the thinking, the intellectualizing can, as you're maybe suggesting, distract us from executing on some of the changes that can then feedback and change our thoughts. And I think there's also the potential risk of attributing some of our behaviors to things that aren't actually true in therapy.
[00:33:01] So what my observation is is that we have two major schools of therapy as far as I can tell. We have the psychodynamic type of therapy, the sort of psychoanalysis where people are lying on a couch and talking sort of in an open-ended way. And that can be every day and can be week after week after week.
[00:33:22] And then you cognitive behavioral therapy where people are trying to change the thoughts and the behavioral patterns that stem from thoughts. And so my question to you is, is this like a third way of thinking about mental health, like not in therapy and just doing the behaviors and sort of societal changes to make behavioral change more easy? Or is it outside of therapy altogether?
[00:33:48] Dr. Boardman: I mean my dream is that one day we will all be put out of business. People won't need us and won't need therapists. And I wish this was part of curriculums and students were taught how to activate change and that this started in, in kindergarten and…
[00:34:06] There's a third type of therapy. You talked about kind of more the psychodynamic talk therapy and then CBT, which is kind of identifying specific negative thinking patterns such as catastrophizing or engaging in black and white thinking. And then what I'm very interested in, and I think of myself as a positive psychiatrist, is kind of a third really complimentary, not an either or, but it's a both, both and kind of situation is focusing on people's strengths.
[00:34:34] What are your strengths, as actually research comparing CBT with strengths-based therapies is what are your top five strengths and there are tests you can do at viacharacter.org, you can take this free test that turns out your top five character strengths. And we know that people who then use their top five strengths in new ways even in a week feel less depressed and less stressed.
[00:34:57] We’re so good at shining the light on our weaknesses and what we've done badly, but looking at our strengths and how we can harness our strengths. Even to look at, there was a study looking at people who had diabetes. How could they use their strengths to be more, to adhere more to their medication regimens? What were ways to kind of align, not their deficits, but what they're good at? We know even that, I think again, kind of part of psychiatry and therapy has become so interiorized, so fixated on the individual and the inner workings of what's going on in your head. And I think maybe at the expense of looking at the community that they exist within, the fabric of their relationships and a little bit too much of this whole idea that happiness only comes from within.
[00:35:43] I'd always argue that it also comes from with. And when we are in a group, a community that is reminding us to take our medication that is there with us, that's helping us use our strengths, it is helping us kind of even where we feel like we are adding value in helping others. I think having a sense of mattering and meaning, it's not just feeling valued, it's also adding value in some way beyond the self. So I do think kind of having a more strengths-based approach to physical illness and mental illness is also really worth our time and our time in the medical profession.
[00:36:20] Dr. McBride: Yeah, it resonates with me what you're saying. For example, I was trying to get a patient last week to think about exercising. It's sort of cliche, the doctors tell people to exercise. We all know it's good for everything from diabetes to dementia prevention. And she was beating herself up because she hadn't been exercising and she had put off the appointment to come see me for two weeks because she didn't want to get weighed.
[00:36:43] And I reminded her, this is not an appointment you can win or lose. This is just a data point and there's just no shame in the number on the scale on my end. But the way I think we're gonna execute on her in getting some exercise is that we looked back at her childhood. What did she like to do before she had a busy job and three kids and a mortgage and it was dance. And so we looked online and found this dance class in her community that’s at the Y and it looks it's not a class that requires designer leggings and an expensive membership. And I was like, just go to one class, just go in the back, wear shorts and just see how it feels.
[00:37:24] And she's like, yeah, I remember being just sort of, entranced by the music and just the movement and the sort of the organic, it didn't feel like exercise. It felt like fun. And I'm like, that's it. That's it. Let's lean into the things that are already in your arsenal of tools. And you know, we gravitate to things as children that we like. That's what we do. We don't have this complicated sorting system in our mind. So I said, just try it. And so I think I hear exactly what you're saying, which is that we have so many strengths, but we tend to focus on the negative.
[00:37:55] We've also lost a sense of community and kind of collective goodwill, I would say, in the last three years during the pandemic and certainly before that, with all sorts of political unrest and social unrest. And I think there's an intrinsic sort of sense of dis-ease among people. At least I see it in my office. And I think what I hear you saying is that you're just building back a sense of community and a sense of purpose outside of our own selves is important.
[00:38:27] Dr. Boardman: Yeah I'm thinking of that study with that looked at asking people to make a New Year's resolution. We know it's very hard to stick to. But those who made kind of individually based ones that were like, I'm going to stop smoking, I'm going to lose weight, versus those that had much more socially oriented resolutions. It was like pro-social, I'm going to walk with my friend once a week. I'm going to meet up with a friend and go to the movies or do a book club. Not only were they going, they were much more likely to stick to it. They were more satisfied over the course of the year. And it was just fun. And I think we have this terrible idea about health is that it has to be punishing and we've got to somehow always be miserable and depriving ourselves. It's full of deprivation and removing that element of joy and others and whatever made you laugh as a child, that you can find things that are fun and that lift you outside of yourself rather than, I think that kind of self immersion that sometimes I think the wellbeing, industrial complex kind of green lights, that's not necessarily healthy. And if anything it can kind of remove us from a lot of those experiences that boost our mental health.
[00:39:42] Dr. McBride: I think it's so true. Okay. I have two more questions. One, what do you think the biggest differences are between in-person therapy versus virtual therapy?
[00:39:52] Dr. Boardman: Call me old… I definitely, just as a practicing psychiatrist, prefer seeing people in person. I think one has a much better sense of who they are in their presence, in their physicality, and I really enjoy it. I mean, I'm grateful for Zoom. I became, you know, it took me a while to kind of get fluent in Zoom in March 2020, but it happened. And certainly I think with online therapy, accessibility is a good thing. The more people who can access therapy really matters, and people are always trying to look at what's the best type of therapy. The best type of therapy is a therapy where you have a good relationship with the therapist, where you trust them, where you feel safe, where you feel connected.
[00:40:34] That's the winning type of therapy. You want to have one argument, I would say, it's just always for quality therapy, not necessarily quantity therapy. I think the idea of being able to constantly text your therapist and actually not speaking to them in real time, I'm not sure about the outcome. I think maybe for younger people, that has been perfectly helpful. There is something though, just to keep in mind. Metabolizing, like when you are having a hard time or something's happened, kind of sitting with those feelings of distress, anger, sadness, frustration, disappointment, and you metabolizing it and knowing that on Tuesday at six o'clock, you're going to maybe address it because it's going to feel really different in the moment versus how it's going to feel, maybe 48 hours or three days later, and sometimes that digested way… and trust yourself, we are human beings. Human beings are supposed to bump into stress, sadness, all these negative emotions. They're information. This is stuff for us to take in and learn from and we don't necessarily need to constantly pick up the phone or text somebody and say, wait, help me. Because I think that really removes agency ultimately and basically suggests that we are ill-equipped to handle these very human experiences.
[00:41:52] Dr. McBride: Yeah. As if you can discharge that emotion by texting and putting it on someone else's plate.
[00:41:58] Dr. Boardman: Yes. Yes, exactly.
[00:42:00] Dr. McBride: So my next question is about medication. There's no kind of short answer to it, but I think we overmedicate people. I think we under-medicate people. It depends on the person. I am a big, big fan of the SSRI medications when appropriate in the right context. What is your general sense of the psycho-pharmacology state of the US right now. I mean, do you see people commonly coming to you who have been on medications that may have been inappropriately prescribed? Do you see people who are just looking for a pill to fix their kind of broken marriage? Do you see it being an asset, a crutch? What's your take?
[00:42:39] Dr. Boardman: I mean, I would say all the above. I think our culture is, Hey, I've got a problem. What's the pill for that? I can't sleep. I'm overweight. Whatever that thing is, I need a pill for that. I'm feeling down. And people feel… even like my kid has an earache, I want an antibiotic prescription. I mean whatever those, there's a culture of satisfaction when you walk out of a doctor's office. You feel like it was a job well done when you have that prescription in your hand. And so people are always blaming the doctors for this. I also think it's kind of cultural, this is the way we've told patients, people to be, they see advertisements all the time for this medication. They go into their doctor requesting that this is going to make me happy. I think of those Paxil ads from the early 2000s of that sad looking blob and then it starts taking Paxil and really happy and like socializing at a party.
[00:43:35] And so I worry about the overmedicating even in ADD. But then you also see in certain populations, it's the exact opposite as you're pointing out people who aren't getting the medications that they need for these issues. So it's not a blanket statement at all. So I'm a big believer in always re-looking at that. Especially when somebody has a tackle box of pills that they take for sleep or anxiety or depression. Wait, how long have you been on these pills? Are they doing what we want them to be doing? And what's the dose? Is this just something that you just kind of keep accumulating over time and you just feel sort of safe doing this?
[00:44:15] And we also know that it’s really hard to get off of antidepressants. It takes time and there's so much research about dosages when you're dialing them up, but not how you dial it down. And people who really feel bad and sometimes they can misinterpret some of their symptoms can feel like depression or anxiety returning when it's actually withdrawal from the medication itself.
[00:44:35] there was a big controversial paper that came out a few months ago, maybe you discussed it on the show, looking at these medications and maybe they're not as helpful as we thought they were. We also do know that there are lifestyle changes that when people. You know, exercise a couple of times a week that they can get the, the benefits of being of like an antidepressant essentially in that movement. It also protects young people against depression, which is so important as well. So I think it's one of those things we have to look at individually, and it's kind of a default answer, but it's kind of a case by case basis. And I know people who've been tremendously helped by these medications as well. So I take it very seriously and I really think of the individual involved.
[00:45:17] Dr. McBride: Same with me. And I think the downside of the article that came out, I think the one you're talking about is the one that said kind of definitively what we've known for a long time, which is that depression and anxiety are not “chemical imbalances.”
[00:45:30] Dr. Boardman: The serotonin hypothesis is debunked.
[00:45:33] Dr. McBride: Exactly. It's not the, it's not a serotonin deficit, which is not to say that increasing serotonin with selective serotonin reuptake inhibitors cannot help. So I think some people took that study and said, oh, then why the hell am I on this Prozac? And stopped taking it. And then other people sort of used it as ammunition to say, you know, modern psycho-pharmacology broken. As with everything, there's nuance, it's somewhere in the middle and it depends on the individual and it requires listening and curiosity about the human in front of us. So Samantha, I am gonna let you go. You've been so full of information and tools and amazing thoughts, and I'm really excited to kick off Mental Health Month with you on social media and to kind of blitz our shared audiences with practical information to be healthier from the inside out.
[00:46:25] Dr. Boardman: Oh, I cannot wait. We're gonna have a great month.
[00:46:27] Dr. McBride: It's gonna be fun. Thank you so much for listening, everybody, and sign up for Samantha's newsletter on Substack, it's called The Dose and I love it. I love the graphics, I really love your logo and I love what you're saying in it, and I read it religiously. I'll see you next time!
[00:46:46] Thank you all for listening to Beyond the Prescription. Please don't forget to subscribe, like, download and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us at [email protected].
[00:47:08] The views expressed on this show are entirely my own and do not constitute medical advice for individuals that should be obtained from your personal physician.
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You can also check out this episode on Spotify!
Did you know things like sugar-free gum, Advil, or simply eating too fast can cause gas and bloating? Everything we put into our ecosystem affects our gut health.
Our gut often reflects our emotional health, too.
In today’s solo podcast, Dr. McBride explains the practical framework she created to help patients conceptualize their health, integrating medical evidence, the patient’s story, and real life.
She calls it the FOUR “I”s:
* Information & data = the elements of our health that we can measure and see.
* Inputs = everything that we put into our health ecosystem.
* Infrastructure = the vehicle (i.e., the skeleton) that drives us through life.
* Insight = the process of laddering up from self-awareness to acceptance to agency over our health and well-being.
It turns out that this framework can help explain and trouble-shoot common gastrointestinal woes.
Health is about more than the absence of disease. Health is about having awareness of data and the stories we tell ourselves, acceptance over the things we can't control, and agency over our life.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription.
You can subscribe on Apple Podcasts, Spotify, or on her Substack at https://lucymcbride.substack.com/podcast. You can sign up for her free weekly newsletter at lucymcbride.substack.com/welcome.
Please be sure to like, rate, review — and enjoy — the show!
The full transcript of the show is here!
Intro: Hello and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today it's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.
[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things: a framework to evaluate their risks; access to the truth and data; and tools and actionable information to be healthy mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.
[00:00:56] Today is a deep dive into gastrointestinal health. There is no possible way I could cover every crevice of the vast amount of knowledge we have on the gut, but I will focus on common things I see and common causes for gastrointestinal distress that often are missed. You may remember from a couple of months ago that I explained in detail the visual representation of how I think about patients.
[00:01:26] I call it the four I’s. It's a two by two grid. Imagine a box with four squares in it. And today what I want to do is talk about the gut and how the different I’s inform gastrointestinal health using some patient examples, things that I see commonly in my office. You can listen to that 15 minute podcast about the four I's for more of a dance remix version of the concept. But briefly, the four i's, are this: the top left square is information. Information and data. Things we can measure, things we can see like lab tests and colonoscopy reports. The top right corner is inputs; things we put in our body from kale and quinoa to alcohol and recreational drugs.
[00:02:15] The bottom left box is infrastructure. Our skeleton, literally the skeleton, literally the vehicle we drive through life, the container of all of our parts. And then finally, the bottom right box is insight. Awareness of the stories that we tell ourselves. Awareness of how our stories manifest in our bodies, and our understanding of our mental health, our anxiety, our moods, our relationships with food, alcohol, each other, and so on.
[00:02:45] So let's talk about a common complaint I see. I don’t think a day goes by in my clinic where I don't see someone who has gastrointestinal complaints like bloating, irregular stools, gas or abdominal discomfort. Now the list of possible diagnoses for these complaints is vast, from diverticulitis to colon cancer to I ate a hot chili pepper.
[00:03:11] But common things are common. That's a very favorite expression that doctors use all the time. And so I wanted to go through how I might conceptualize thinking about the diagnosis or how to help a patient troubleshoot these symptoms when it's sort of bread and butter. Take a middle-aged guy who comes in complaining of bloating, gas, and irregular bowel movements.
[00:03:32] When I think about the top left square, that information, I want to know, what do his lab tests look like? If he's over the age of 45, has he had a colonoscopy? Because 45 is the age where we start screening colonoscopies. By the way, if you have a family history, you should start earlier. So I want to know what's going on internally.
[00:03:52] What's his information? For example, if his lab tests show that he has hyperthyroidism or liver enzyme abnormalities, or a pancreas problem or celiac disease, that may directly inform how I'm going to recommend treatment. In other words, the data and the things we can measure are very important. So let's say he had a normal colonoscopy.
[00:04:14] Let's say his liver tests are normal, his pancreas is normal, his gallbladder is normal, and his blood counts show no evidence of infection or inflammation, and he's negative for celiac disease. So those are just some broad brush stroke tests I might order. I also might not order tests because sometimes it's a simple solution, but let's say that his information is normal.
[00:04:35] Then we'd move over to the inputs. That's the one I'm most interested in. When people have these kinds of complaints, I want to know, how much alcohol do they drink? What is the cadence of their eating? Are they eating a lot of processed, greasy food? Are they consuming a lot of sugar? What's the level of acidity in their diet and how fast do they eat? People who eat fast often swallow a lot of air and can get gas in the colon. Do they drink a lot of soda? Do they chew gym? Sugar-free gum is notorious for causing gas and bloating. So I would do a thorough history of what the patient's inputs are. What are they putting in their ecosystem?
[00:05:15] Sometimes people can get gas and bloating from taking too much fiber. I think most people know that fiber is healthy and fiber can help with digestion. But if people escalate the dose of their fiber intake too quickly, that can backfire and they can get bloating and gas. This is a common phenomena. The other thing I would ask in the input department is, are they taking any supplements or vitamins? Because even though supplements and vitamins are considered natural, sometimes they contain fillers or the supplement itself can accidentally cause bloating and gas. Magnesium, for example, which people often take to help them sleep, can cause diarrhea.
[00:05:50] It’s important to think about all the different things you put in your ecosystem and how they might affect your digestive health. One of the most helpful interventions I find for patients with this kind of complaint is to keep a food journal. It sounds really boring and it sounds kind of onerous, but writing down every single thing you eat is kind of an interesting exercise.
[00:06:12] People often connect the dots between their digestive health, their mood, their energy, and their bloating and gas when they look at the things they're eating. It's really interesting how mindlessly we consume foods, supplements, vitamins, and how little attention we pay to the things we pop into our mouth all day long. So I would suggest writing things down if you haven't done it already and you have this complaint.
[00:06:35] The next quadrant I would look at is infrastructure, our skeleton. So it's not uncommon for people who have a bum hip, a bum knee, an aching back to pop an Advil, to take Tylenol, to take supplements that are over the counter that they think will help with their achy joints and skeletal health. One of the more common triggers of gastrointestinal stress is NSAID's, non-steroidal anti-inflammatory medications. Advil is one of them. Aleve. Naproxen. So we want to think about are we taking any medicines to treat our skeletal woes? And then we can also think about pain and how pain itself can cause distress. Distress can show up in the gut.
[00:07:17] The other thing we need our skeleton for is just basic, everyday mobility. If we have some sort of limitation in our mobility, or we're just living a sedentary lifestyle, like we sit behind a desk most days, then that can affect our gut function, too. Often, one of the solutions for a chronic constipation is just regular walking, regular exercise, hydration, and movement to get our motor running. Our infrastructure really does matter. Sometimes just moving our bodies, hydrating and avoiding Advil is the way to keep our gut healthy.
[00:07:49] Moving over to the insight quadrant, it never ceases to amaze me how patients will report to me these terrible gastrointestinal woes. We will think it may be an appendicitis, a diverticulitis. They will have a colonoscopy, they'll have extensive lab work and maybe even a CAT scan. And some of the times we find a diagnosis, someone has diverticulitis and I put them on ciprofloxacin and Metron dissolve for 10 days and they get better. Other people have a diagnosis that we can name through blood work like celiac disease or inflammatory bowel disease like Crohn's or ulcerative colitis.
[00:08:24] When a patient has gastrointestinal distress and we have no obvious cause, tis is when I get my mojo on because I love talking about how our gut is often the home for our emotional health. It sounds kooky to many people, but I see it every day. Stress and anxiety in particular can manifest itself in our gastrointestinal tract. So when I have a patient who has a normal set of labs, normal imaging, a normal colonoscopy, and they're still suffering, we default to calling this irritable bowel syndrome. Now, patients often don't like having that diagnosis because they consider it a throwaway diagnosis. And I totally understand that because being diagnosed with IBS or Irritable Bowel Syndrome feels like the medical establishment is dismissing the patient.
[00:09:13] It’s like, we can't figure it out. We're gonna slap a diagnosis of IBS on it, and say, “see you next time, good luck.” But irritable bowel syndrome is a real phenomenon. It is literally the spasm and irritability of our colon, and it's from something. Just because it's IBS doesn't mean it's not real. IBS, however, is not a life-threatening diagnosis. It is not a result of inflammation. It is simply a functional issue that is often driven by emotional distress. One of my favorite exercises with patients is to take inventory of where they are on the continuum of anxiety. Where are they on the continuum of mood? Where are they on the continuum of their relationship with work, parenting, caregiving and just being alive in the modern world.?
[00:10:03] In other words, we all have fears. We all have moods, we all have relationships to food, alcohol, our work, and to each other. When those things are on the fritz, when our anxiety is out of proportion to the actual threat; when our moods are not stable, despite our best effort to get sleep and to get exercise; and when our mental health is not in balance; those are often the triggers for gastrointestinal distress. So sometimes, dare I say, often the solution for gastrointestinal woes, if we can't find an obvious cause again, to identify thoughts, feelings, and behaviors that are causing us to feel distressed. In the short term, I will recommend to a patient that they try this, I don't wanna call it a diet because diet to me implies weight loss, but there's a diet, or actually call it a framework called the low FODMAP Diet.
[00:10:55] You may have heard of the FODMAP Diet from a friend or on the internet or on Instagram. And when people say the FODMAP diet, they often mean a diet that is low in FODMAPs, F-O-D-M-A-P-S. And the diet is really designed to help people with irritable bowel syndrome, and one of the problems I think people run into is I give them the list of foods and they accidentally hear me say, cut all these foods out of your diet and good luck.
[00:11:20] That's not my plan. All I want people to do is use that list of foods that are potentially irritating to the gut, that potentially accelerate that gastrointestinal spasticity and see if they can connect the dots between what they're eating by that journal we talked about and how they feel in their gut. FODMAP stands for Fermentable, oligosaccharides, disaccharides, monosaccharides, and Polyols.
[00:11:45] What that basically means is that these are some foods that the small intestine absorbs very poorly, and people can experience cramping, diarrhea, constipation, bloating, and gas. So one of the occupational hazards of recommending the low FODMAP diet to patients is that people often go and restrict and then feel worse.
[00:12:03] Maybe their diarrhea and cramping is better, but they're hungry. So the other potential occupational hazard of recommending the low FODMAP diet is people using the diet as a panacea and not then addressing the other triggers of their irritable bowel in the first place. From work stress to the Advil they took for the headache to the alcohol they overdid and kind of forgot they did because they didn't count it because it was the weekend.
[00:12:29] In other words, there's really no one size fits all prescription for IBS/irritable bowel syndrome. But in my experience, it's usually a little bit of a lot of things and it's usually one little piece of something from the information quadrant. Maybe you have a predisposition to constipation or diarrhea given your family history.
[00:12:51] It's one little piece from the inputs, like maybe you had too much alcohol and you didn't really register it, or maybe you're eating too much tomato or Brussels sprouts. Maybe it's in the infrastructure space where your body isn't moving enough. You need to give your body and your colon a little more time and space for activity.
[00:13:09] And then sometimes it's in the insight. We need to recognize that our stories live in our bodies, and that self-awareness is often the key to health and wellbeing. So that is my little spiel about gastrointestinal health. It's pretty basic, but I find often that when we have these symptoms, we tend to overdo and over-test and over-worry when actually some of the solutions that I find the most helpful are really, really simple.
[00:13:35] It's paying attention to thoughts, feeling. Taking stock of what we're putting in our body and our everyday habits, and then thinking from the ground up about how to be more self-aware and how to problem solve using a very basic set of tools we already have inside us. I hope that's helpful. If you enjoyed this podcast, I would be so happy if you liked it, if you subscribed, and if you recommended it to a friend. Thank you so much for joining me, and I'll see you next time.
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On this episode, Melissa Urban talks candidly with Dr. McBride about her struggle with drugs—and how her recovery stemmed from creating healthy boundaries around food, substances, and interpersonal relationships.
Her latest book, The Book of Boundaries, is about the importance of setting limits on relationships and choices, and putting ourselves back in the driver’s seat of our health and wellbeing.
Melissa is living proof that health is about laddering up from self-awareness to acceptance to agency of our body and mind.
Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast or at https://lucymcbride.Substack.com/listen.
Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome
Please be sure to like, rate, review — and enjoy — the show!
The full transcript of the show is here!
Dr. McBride: [00:00:00] Hello, and welcome to my office. I'm Dr. Lucy McBride, and this is "Beyond the Prescription," the show where I talk with my guests, like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as more than the absence of disease. As a primary care doctor for over 20 years, I've realized that patients are much more than their cholesterol and their weight. Our stories live in our bodies. I'm here to help people tell their story and for you to imagine and potentially get healthier from the inside out. You can subscribe to my weekly newsletter at lucymcbride.com/newsletter and to the show on Apple Podcasts, Spotify, or wherever you get your podcasts. So let's get into it and go beyond the prescription.
Today's guest has been on the New York Times' bestselling list six times. She is the creator of the Whole30, which is not just a diet plan. It's a way to rethink our relationship with food. Melissa Urban joins me today to talk about overcoming addiction and the lessons learned in recovery that inform how she thinks about food, nutrition, body image, and the boundaries we set in our everyday lives. Melissa's newest book is called "The Book of Boundaries," published in October 2022. In it, she describes how we can say yes to things we need and want and no to things we don't to put ourselves back on the driver's seat of our health. Boundaries, in my world and in hers, provide the groundwork for improved health and well-being. Melissa Urban, thank you so much for joining me today.
Melissa: [00:01:48] Thanks for having me. I'm excited to chat with you.
Dr. McBride: Here's why I wanted to have you on the show. The way you talk about boundaries and the importance of setting limits on our relationships, our choices, is so important to how we show up in the world, how we relate to food, how we relate to alcohol and other substances, how we relate to other people, and how we feel about our own bodies that it's really at the core of what, in my opinion, health is.
[00:02:17] Health, as I introduce in this podcast, is about self-awareness, and it's about acceptance, and it's about having agency. And having agency, in my opinion, includes knowing what we need and knowing what we don't need, which is driven, ultimately, by knowing our value and our meaning and our purpose. So that is a wide lens with which to open the conversation and for me to ask you, Melissa. How do you, as an expert in nutrition and eating and health, define health yourself?
Melissa: Well, that's a big question to open with. You're just going right for it.
Dr. McBride: We're going to go right from the top, and then we're going to get granular.
Melissa: [00:02:57] I had to do a piece recently for Oprah Daily where we talked about the concept of wholeness and what does wholeness mean to me, and I think that that can relate very nicely to this idea of what health means to me. So I think, very often, we look at health through a very narrow lens, and often, when it comes to diet culture, it's through the lens of body size. I mean, they are just absolutely equated that the smaller your body, the healthier you are. If you take a step back from that, maybe you're looking at health from the perspective of, "What does my diet look like? Do I have a movement practice? What does my sleep look like?"
[00:03:31] But even more than that, there are so many different factors that make up this concept of health or wholeness. I'm looking at it from a physiological perspective. So, do I have the energy to do the things that I want to do in my life to keep up with my kid, to do the recreational activities that make me happy? Do I feel satisfied from a personal development standpoint? Do I feel like I'm working on myself and I have the time and capacity to do some self-awareness or do therapy? Do I feel like I have a spiritual practice, whatever that looks like? Whether I'm connected to God or the universe or just my own highest self, am I cultivating that spiritual practice? Do I have social health? Do I feel like I have good connections with other people in my community? Do I feel like I have support? Do I feel like I'm not isolated?
[00:04:16] I think there are a lot of different aspects of health. You have to look at them from a position of wholeness. You can't just look at any one aspect, because one aspect can be going very, very well, but if all of the others are falling behind or you're not paying attention to them, to me, that doesn't feel particularly healthy or feel like thriving.
Dr. McBride: You couldn't have said it better, and it dovetails exactly with the way I think about health. It's not about the absence of disease. It's about the integrated sum of different components. It's about nutrition, body mechanics, self-awareness, which includes awareness of our medical vulnerabilities, which are often genetic and environmental, and it also includes, as I said earlier, that sense of agency. When I think of agency, I think of the ability to execute on goals that are yours and only yours. That's a luxury for a lot of people to have the opportunity to grow and to personally grow health-wise, grow professionally, grow relationships. But I think agency can also be on a really small level, feeling more in control of our everyday habits and even our everyday thoughts.
Melissa: [00:05:21] I agree. You know, when you say agency, I immediately think about self-efficacy, this idea that, like, I feel as though I am able to accomplish the things that I want, and sometimes that involves, if I think back to my recovery and the serenity prayer, giving me the patience to accept the things I can't control and, leave them out, but recognize that, for the most part, I do have control over how I choose to respond to those situations in that I usually or almost always can have agency. And again, there's an element of unacknowledged privilege in that statement alone, but we'll just say that agency, to me, does involve this aspect of self-efficacy and recognizing the things that I can't do while making strides on the things that I can.
Dr. McBride: [00:06:02] At the risk of repeating myself on this podcast, and my listeners may be, like, "Oh my God, there she goes again, talking about the serenity prayer," the serenity prayer, like, it's kind of the final common pathway of so many different conversations I have with patients, whether it's about parenting, like, letting of the fact that your teen doesn't want to talk to you right now and accepting that's normal for their age, and leaning into the opportunities, you have to talk to them when you're driving a car and it's quiet and there's no eye contact, to managing your addiction to alcohol, accepting you don't have control and leaning into the parts of your life that you do have control, finding joy and pleasure in other places and asking for help.
[00:06:40] I’d love to, therefore, pivot to the conversation about your addiction and your health, because you grappled with addiction to heroin, cocaine add other substances. And so I'm aware that you, like so many of us had enormous struggle as a younger person, and I'm imagining also that informed a lot of how you are today and show up today. Can you talk a bit about that process, not that that can ever be encapsulated in a quick podcast?
Melissa: [00:07:15] Yeah. I mean, you know, my drug addiction started when I was about 18, and it came as the result of some sexual abuse I experienced at 16 by somebody I was very close to. And I had just...you know, after that experience, I didn't tell anyone for a year. I didn't know how to handle it. When I did tell my family, they didn't respond super well. It was a really challenging situation that I was definitely not equipped to handle. And so I was looking for ways to essentially escape my own life. And I tried drinking, and that didn't work. And I tried restricting my eating, and that didn't work. And I tried dating guys who were terrible for me, and that didn't work. And it wasn't until I tried drugs that I was like, "Oh, this is it. Here we are. Here's the thing that can pull me so far away from myself." And I was addicted for...
Dr. McBride: Can I interrupt you for a quick second?
Melissa: Yeah.
Dr. McBride: [00:08:00] I'm going to guess you weren't aware at the time you were dating the wrong guys and restricting calories, that you weren't aware that you were self-medicating. You were just doing it. Or were you that aware of your own pain?
Melissa: I was pretty aware.
Dr. McBride: You knew what you were escaping, like, "Oh, I'm going to go, like, looking on a menu of things to self-soothe. And here they are."
Melissa: [00:08:17] I don't think I could go that far, but what I knew was that I did not want to be in my own life, and I was very actively looking for things that would take me away. I don't think I could have explained it any more eloquently than that at the time because I didn't have the language and I didn't have the tools. But I knew that I was hurt so much, and I didn't want to be there, and I was looking for something to take me out a bit. That was about my experience.
Dr. McBride: It's interesting because, as you know, sexual abuse, sexual trauma, is so common and so commonly ignored by all parties. Like, because it's so stigmatized and so shameful to talk about in people's minds, people often don't know they're self-medicating. They don't know until they're in a real bind that their alcohol use is related to that trauma. And it's not a lack of intelligence, it's just a lack of insight. So it's impressive to me that, at an early age, you knew your feelings and you just didn't have an outlet.
Melissa: [00:09:09] My sexual abuse was, like, a record scratch in my life. Up until that point, I was the good kid. I didn't get in trouble. I got good grades. I read a lot. I was quiet. Everybody liked me. But, like, I wasn't super popular. I mean, it was a very middle-of-the-road. Like, I was about as even-keeled as they came. And then, after that incident, everything went sideways, my behavior in school, I started acting out, my behavior with my family and with my parents, I started dressing differently. So, to me, it was very obvious that all of these things were related to this incident of sexual abuse, but I hadn't told anybody. So, to everyone else, it looked like it was coming way out of left field, but I knew what was happening.
Dr. McBride: You didn't want help in the beginning, right? You wanted to hold that boundary so tight that you weren't going to let people in. But, like, what happened? When did you get kind of caught or busted, or when did you get enough insight to know this is a real problem and affecting your everyday health?
Melissa: [00:10:00] Pretty dang early on, you know. I dove in as hard and as fast as you could. I didn't have a drug of choice, which I now know is quite unusual. I only dated drug dealers for five years. And very quickly, I realized that this thing that I was using to escape from my problem had now become a problem unto itself, and now I had a problem layered on top of problems.
And I was like, "Well, I'm this far in. I don't really know what else to do." And so this is the cycle that addicts get stuck in, whether you're talking about food addiction or drug addiction or alcohol. I overconsumed, and I hated myself for it. And I had guilt, and I had shame, and it led to isolation. And that led to stress, and that led me to overconsume the very thing that I hated myself for doing. And I was stuck in that cycle for a very long time because I didn't know how to get out of it.
[00:10:45] And it wasn't until I had this moment of, like, literal divine intervention with a boyfriend who was miraculously stable and wasn't a drug addict who gave me, essentially, an ultimatum and said, like, "You need to go to rehab. I can now see how problematic your behavior is and how much you're killing yourself. And, like, I really want to see you go. Would you consider going? And if you can't go, I'm going to have to leave. I can't watch you do this to yourself." And in that moment, I somehow found the strength to be, like, "Okay, I'll go."
Dr. McBride: That person set a really good boundary, and they knew what they needed from a relationship, and they were trying to use their own healthy boundaries to help you. It's just an important moment in your life.
Melissa: [00:11:21] He's my favorite ex-boyfriend, for a reason. I talked to him not that long ago. We texted, you know, just a couple of months ago, and I was like, "Hey, in my book, I'm still calling you my favorite ex-boyfriend." And he's like, "I will always cherish that," you know. But, yeah, he literally saved my life, and he did set boundaries with me. He set boundaries while I was using. He would say, "We can't have this conversation if you are this high. So when you come down, let's talk because we need to talk," or "It's okay that you stay out late, but you need to call me to let me know where you are. Otherwise, I worry." He tried to set boundaries for me for his own protection because I was destroying him and the relationship, and ultimately, that was what got me to rehab the first time.
Dr. McBride: [00:11:59] One of the things I find so interesting and this is getting really granular, is, like, what was it about him that allowed you to trust and receive that message? In other words, I'm guessing there are other people in your life who were, like, "Melissa, get a grip. Melissa, you're sick. Melissa, you need help." What's interesting to me is, like, the messenger in that moment and who has access to someone who needs help and who needs to make important changes in their lives. And I wonder what it was about him that gave you the kind of confidence and openness to receive that message, given that I'm guessing other people had said similar things.
Melissa: [00:12:33] It was the moment. I remember very clearly sitting on the couch. I had just been paid. My money had been... Because I was very functional as an addict. I still had a job. And I had just been paid, and all the money was in my bank account. And I remember him saying, like, "I need you to go to rehab, or I'm going to have to leave." And I remember calculating how much heroin I could buy with the money that was in my bank account and knowing, if I did that, that I would die, and not really caring that much, and having just a split second moment of "You could have something different." And in that split-second moment, I was like, "Okay, I'll go." And faster than I could even take it back, he was on the phone. He found me a bed. Like, I say it was divine intervention because it really feels like that.
Dr. McBride: It also sounds like he wasn't judging you or shaming you.
Melissa: No. He was sad for me. He knew who I was earlier in my addiction. I was always using when I was with him, but I was nowhere near as bad off as I was at the end. He really hated to see me do this not only to our relationship and to him but, like, mostly to myself.
Dr. McBride: [00:13:28] In order to access other people and their willingness and ability to make changes, whether it's around food or other habits, to me, the messenger has to be free of judgment and someone they trust and then lead with empathy and curiosity. I find that if I'm counseling someone who's an addict on not just the benefits of quitting alcohol for them, because people often know the health benefits, but the other possibilities of how their life could be going and what other root causes that underlie this self-destructive behavior, coming at those conversations with blame, shame, and declarative statements does not go well.
[00:14:12] In fact, I don't recall ever having a conversation with anybody, including my kids and my spouse, about changes, from doing the dishes or whatever, that landed well when you lead with shame, blame, and declarative statements. But, hey, I wonder if you could connect the dots between the way you relate to alcohol to that childhood trauma you told me about, similarly, I might say to my kid. I wonder if you thought about doing the dishes as part of the family unit. In other words, questions instead of declarative statements.
Melissa: [00:14:42] There was nothing at that point that anybody could have said to me in terms of trying to shame me or blame me or disparage me that I wasn't already saying to myself 10-fold. Nobody could ever say anything to me that would be worse than what I had said to myself. And at that point, I was really struggling with, like, do I even have any worth or value left if I do enter into recovery? I'm going to have so much harm to repair. I'm going to have so much life to rebuild. It really did feel hopeless in that moment. But, you know, I had so much privilege, again, going into my recovery.
[00:15:17] I had a family who had not abandoned me. I called my mom from rehab, and she was, like, shocked and upset. And she was, like, "Okay, let us know when we can come visit." I had a boyfriend who was there and ready to protect me. I had a decent job with health insurance so I could go through rehab and spend time in counseling and have that covered by insurance and a job who said they'd hold my job for me. Like, in terms of my recovery, I had everything going for me, and all I needed to do was show up and do the work, which is so much more advantage than so many other people have.
Dr. McBride: [00:15:45] One hundred percent. And I'm sure you would agree that if everybody had access, unfettered access to mental health services, addiction, and rehab services and had a doctor, a nutritionist, priest, rabbi, who could talk about addiction in a matter-of-fact way, lead with curiosity and empathy, and know that the person they're talking to is already filled with shame, and then we could talk about mental health issues like we do any other physical health issue, we would be in a world of a better place.
Melissa: It would be a very different environment. You know, I've been in recovery for almost 23 years now, so this was a very long time ago. We are much more free now in talking about mental health, in talking about recovery, in talking about addiction. There's a lot of destigmatizing that has gone on, at least in certain circles, right? If you're on those sides of TikTok and Instagram, people are very free, and you're even seeing it at the highest level of media, you know, when you have champion tennis players talking about taking a break or gymnasts talking about taking a break for their mental health. It is now something that we are effectively working to destigmatize. Twenty-three years ago, it was even harder. So I want to continue to see the progress that we have made, and I want to see that progress continue to increase.
Dr. McBride: I totally agree. And I think, as I say to patients all the time, when we talk about mood or anxiety and they're kind of wondering why I'm asking, I remind them, we all have mental health. It's a feature, not a bug. It's something that you either address or you don't address.
[00:17:15] And to you, Melissa, I'd love to ask you next, how did your mental health and recovery process inform the decision to start the Whole30? And how did the lessons you learned about yourself in recovery inform how you talk about food?
Melissa: There's so much recovery language built into the Whole30 that I did not even recognize when I wrote it, but other people who were also in recovery would show up at a seminar and they'd be like, "Are you a friend of Bill W.?" And I hadn't talked about my recovery for the first year or two that I was running Whole30. And I was like, "How did you know?" And it was like, "Oh, it's, like, these six terms and phrases that you've used in these seminars." When I got out of rehab the second time, because I had a year of recovery and then I relapsed, which is very common, and then the second time I, [00:18:00] you know, entered into recovery, I realized I had to change everything about my life if I was going to maintain my recovery.
[00:18:05] I needed to become a healthy person with healthy habits immediately. I had to adopt that identity, create that growth mindset, set in whole boundaries with other people and myself, and that was when I started going to the gym and eating healthier. I made a new group of like-minded girlfriends who ran instead of drank, and we would go for morning runs instead of go out for drinks at night. And I changed everything about my life. And that led me to, in 2009, this 2-person self-experiment that was to become the Whole30. And, you know, for 30 days, we eliminated foods that are commonly problematic to varying degrees according to the literature to see if they were problematic for us.
[00:18:44] And while I experienced incredible physical benefits from that Whole30 energy, sleep, mood, performance in the gym, recovery, the most important thing that my first Whole30 did for me was identify the ways that I was using food like I used to use drugs, as punishment, as reward, to self-soothe, to cope, to relieve anxiety, to show myself love. I didn't have any other coping mechanisms. And it wasn't until I took those foods away for 30 days that I was like, "Oh, crap, I have to figure out how to sit with discomfort and not automatically look to food or drink to, like, numb or run away from that." And my behaviors with food were relatively healthy. I wouldn't call them incredibly dysfunctional, but I came away from that first Whole30 with so many more tools in my toolbox. It radically transformed, permanently transformed, my relationship with food. And that was such a powerful experience that I was like, "Okay, I wanna tell other people about it and share about it."
Dr. McBride: It's incredible what you've done. I mean, I was just in the grocery store earlier this week, and I'm looking at a label on something, and it had a Whole30 label. I'm like, "Oh my gosh, that's my podcast guest."
Melissa: I know her.
Dr. McBride: [00:19:49] Yeah, that's cool. I mean, it's extraordinary what you've done, particularly, the nuanced way you talk about food. Like, I notice, even just when answering my question now, you don't talk about eating healthy. You talk about eating healthier, meaning, it's all relative. It's not a black or white, on/off, kind of binary system you're talking about. The way this shows up in my office as a primary care doctor, as you imagine, I have people who ask me about, "How do I lose weight?" all the time. And some of them need to because they have metabolic syndrome, diabetes, you know, heart disease, high cholesterol, the various consequences of extra weight or poor health habits. I also have patients asking me all the time, "How do I lose weight?" And they don't need to lose weight. It's more of a body image, you know, often informed by kind of the subtle cruelty of diet culture that infiltrates the minds of women more than men, but women, in particular.
[00:20:42]So I guess my question to you is, given that the Whole30 does involve elimination and sort of draconian measures in the first 30 days of no sugar, no alcohol, no caffeine, no gluten, no dairy, how do you talk to audiences about the harms of restriction, balanced with the benefits of understanding exactly what you're putting in your body and the emotional, physical, and medical effects of them?
Melissa: I mean, this is an incredibly nuanced discussion, because diet culture and anti-diet culture are just two ends of, like, a very long spectrum.
Dr. McBride: You said it.
Melissa: [00:21:22] The Whole30, as we've alluded to, is not a weight loss program. We are not a prescriptive approach in that Whole30 doesn't say, "You should eat like this forever." We also don't categorize foods as good or bad. There are no good or bad foods, and you are not good or bad when you eat food. We remove all morality from the equation. What Whole30 is is a self-experiment, because any medical doctor or registered dietitian will tell you, there is no one-size-fits-all when it comes to diet. You have to figure out what works for you. And your patients say, "Yes, that makes so much sense, of course. How do I figure out what works for me?" And so Whole30 is the answer to how.
[00:22:02] It's a 30-day elimination diet, and elimination diets have been around since the 1920s. Many medical doctors still consider them the gold standard for identifying food sensitivities. What the Whole30 does is it eliminates foods for 30 days that are commonly problematic to varying degrees across a broad range of people. We pull these foods out for 30 days and see how the elimination of these foods impacts your energy, your sleep, your mood, digestion, cravings, joint pain and swelling, acne, allergies, asthma, anxiety. All of these conditions can be impacted by the food that you eat. At the end of those 30 days, you'll reintroduce those food groups one at a time very carefully and systematically, like a scientific experiment, and compare your experience.
[00:22:48] Based on what you learn through the Whole30, you will then have a blueprint for how foods work for you and your unique context, and you'll be able to take that to create the ideal sustainable diet for you according to your definition of health. We don't prescribe that for people. As you've mentioned, there is an element of restriction to Whole30, which is why we don't suggest the program for people who have a history of disordered eating or eating disorders. Any program with restriction can be triggering, so we are very open about that and very encouraging of those folks to work with a qualified healthcare provider to see whether or not Whole30 or some modified version of Whole30 might be right for them and make sure that they're completing the program with supervision, if at all.
However, when you look at most weight loss diets that involve restriction, you're talking about restriction maybe of entire food groups but also specifically of calories. And when you restrict calories and either macronutrients, micronutrients, or both, that obviously sets the body biologically for that rebound effect that almost always happens at the end of a weight loss diet, because you are underfeeding yourself, undernourishing yourself. The Whole30 does not have that aspect. We don't count calories. We don't restrict calories. We don't restrict portions. We're eating three, four meals a day to satiety, real whole nutrient-dense food.
So, from that perspective, you don't have the same physiological rebound effect to the restriction of calories on the Whole30 that you might have with other plans, which can help people feel more satiated, more satisfied, and not deprived for those 30 days if they choose to take on this self-experiment.
Dr. McBride: You explained that so well. In practice, as you might imagine, I see lots of patients who undertake diets for the wrong reasons, or they're well intended, meaning, like, they actually need to lose weight because they have type 2 diabetes and they need to lose 50 to 100 pounds, but they haven't set themselves up for success because they haven't fully understood what a program can and cannot do for them. For example, there are certain diets, which will not be named, that basically give you fake food, and indeed, you will lose 10 pounds to fit into the mother-of-the-bride dress in 2 weeks. But you will inevitably feel ashamed when you can no longer keep that up, because who can eat fake food unless you're a robot, and then you gain all the weight back.
I have patients all the time who are valiantly trying to lose weight without connecting the dots between the real parameters of their everyday life and setting themselves up for failure by saying, "I'm gonna chop vegetables. I'm going to prepare a protein-rich meal and quit alcohol in perpetuity." And then, if they have a full-time job, and they've got kids, and they travel for work, the wheels fall off the bus. In other words, what I see being successful in practice is when a patient's expectations are managed for what a behavioral change can and cannot do for them when it comes to food or anything else, when they have a healthy respect for behavioral patterns that are paved like concrete highways in their brains that are hard to break up, and they're willing to alter habits, and they have the time, energy, resources, space to make changes, and they're not looking just at the number on the scale. They're looking at the metrics of how do I feel, how's my sleep, how's my energy, how's my poop, how's my sex drive, how's my ability to concentrate at work. And when people can take away that obsession with the number on the scale and even their A1C diabetes test, which we need to see, but isn't the end all, be all. When they look at how they feel and how they are in their bodies, then people are setting themselves up for success in a sustainable way.
So what I like about Whole30 in the way you described it is that, yes, there are gonna be people who use it for the wrong reasons, people who don't need to lose weight and are starving themselves not just for 30 days but for 60, 90, 100 days. But when a patient is given the framework within which to think about this change, and they are looking at the right metrics, it can be successful. It can be a knowledge exercise. It could be an exercise in understanding what works for their bodies.
Melissa: It's a huge exercise in self-efficacy as well, because it's not easy, right? And here's the thing, we know that people come to the Whole30 and say, "I know you're not a weight loss diet, but I'm still trying to lose weight." And it's like, "Okay, I respect that. You have the right to do with your body as you choose. That's not my business." But if they stay connected to Whole30 through any medium, whether they're reading a book, they're on our social media feed, they're watching my YouTube live, they're getting our email newsletters, you are getting every single moment of every single day focused on no-scale victories, "Here's your Whole30 mindset and how it differs from your old diet mindset. Here's how you can restore that connection with your body and learn to trust the signals that your body is sending you, because your body knows better than any calculator on an internet how much you should be eating." Those are the messages that you're getting.
We invite people to take a well-deserved 30-day break from hyper-fixating on that number on the scale as your only success metric and look at all of the other benefits that changing the food you put on your plate can bring into your life and what that does for literally every area of your life. The Whole30 is about food, but it's about so much more than just food. And when people do the program and they feel that sense of self-confidence and self-efficacy, the only benefit you had from the Whole30 was that you ate really good whole food for 30 days, like, you know, nutrient-dense, vitamin-dense, micronutrient-dense food for 30 days, and you kept a promise to yourself. I would call that a home run.
Dr. McBride: One of the harms, in my opinion, of diet culture, mixed with hustle culture, mixed with social media, mixed with just the modern world, is that so many people have lost touch with hunger and satiety cues. In other words, patients commonly will say to me, "I've cut out alcohol. I've cut out gluten. I'm not eating as much overall, and I can't lose weight." If they actually need to lose weight, I will talk to them about what the cadence of your eating is like during the day. Because sometimes people aren't losing weight as they want to and need to because they aren't eating enough. They aren't in touch with their hunger and satiety cues. And I think when we're busy, when we're eating on the run, when we count coffee as breakfast, a KIND Bar as lunch, and then we don't eat all day because we're so busy, and the floodgates open at 7:00 at night, we lose track of what does it feel like to be hungry and what does it feel like to be sated.
I don't know if this resonates with you, but I talk with patients commonly about hunger being, [00:29:30] like, a wave. You're gonna notice it rising. I'm not a surfer. But you notice it rising, and you notice it about to crest, and that's when you wanna eat. If you're tangled with your proverbial surfboard in that crashing wave, you're going to overeat, you're going to overeat the wrong stuff, and then you're going to feel bad about the next day. But if you can understand your cues, which often get lost in our everyday lives, that can do so much good.
Melissa: I mean, it's not just that they're getting lost. It's that, if you have been weight loss dieting, you have conditioned yourself to not pay attention to those cues.
Dr. McBride: That's right.
Melissa: Your body says you're hungry, and you're like, "No, you're not, because I don't have any points left today," "No, you're not, because you can't eat lunch until 1 p.m.," "No, you're not, because you just ate your 100-calorie snack bar, and that's the only snack that you're allowed to get." So there are a lot of experiences, especially for women, that disconnect us from our body. Maybe it's religious influences. Maybe it's diet culture. Maybe it's trauma. But we lose that connection, and then we're told over and over again that we can't trust our own bodies.
Dr. McBride: [00:30:30] One hundred percent.
Melissa: So one of the biggest benefits of Whole30 is, like, restoring that connection and saying, like, "Yes, you can trust the signals that your body is sending you and to start to tune back into that."
Dr. McBride: Yeah. I mean, so many of my patients who are in recovery for disordered eating, we talk a lot about just trusting the neck down again. This is not, like, the CEO and then your body is the, like, chief operating officer, right? It's not supposed to take marching orders from your brain in its rigid form. It is integrated. Your body can actually give you all the information you need, and your body is your friend. If I had one message to give patients who are struggling with weight or relationship with food, it's, first, try to get back in touch with your hunger and satiety cues and give yourself permission to notice hunger and to feed yourself and to be sated. Satiety is one of the best things for calming anxiety, for focus, for concentration. It's normal. And pleasure is not something we should be avoiding. Even if it's by eating a chocolate bar, that's okay.
Melissa: [00:31:29] Absolutely. You know, I talked earlier about how I used to cope all the time with food with self-soothing and relieving anxiety. And I still do that sometimes in a very conscientious way, and it still feels good. And I feel good about it, but that is no longer my only coping mechanism. And I think that's the difference. I now have a therapist, and I talk about my feelings with my husband and my friends, and I journal, and I walk, and I hike, and I meditate, and I reparent, and all of these other coping skills that now are just this, you know, nice, holistic picture of ways that I relieve anxiety and discomfort and self-soothe. Food is still one of them, but it's not the only one. And I no longer have the shame or guilt or negative self-talk associated with it. And I think that's the difference.
Dr. McBride: You are really on the other side of that recovery, and I love what you just said, which is that recovery includes pattern repetition, repetition compulsion. As long as you know that that's happening and you forgive yourself for having dessert or you open a pint of ice cream because you're sad and you eat it, like, that's okay. That doesn't mean you're "relapsing" or morally flawed or gonna gain 100 pounds. It just means you're human.
Melissa: Yeah. I mean, the other day, I was having a really hard mental health day, and I said to my husband, "Today is the day that I'm gonna skip the gym, I'm gonna sit on the couch, and I am just gonna eat whatever comes up for me." For me, on a normal day, those might be seen as not healthy behaviors. Skipping the gym is, like, not typically what I do, because I love going to the gym. But on this day, that felt like the thing that I could do that would nourish myself the best, and I was still conscientious and deliberate in how I chose to do it. I loved every second of sitting on my couch, watching Netflix, eating Smartfood Popcorn, and then, when it was done, I was like, "Okay, all right, that felt good. But that's not sustainable, and I don't wanna do that again tomorrow. What am I gonna do tomorrow? Because I still don't feel great, and although that was nice, I need another tool from my toolbox." And that's what I did.
Dr. McBride: You're so wise. One of my favorite expressions is this, and I actually just used it with my daughter who is feeling guilty about saying no to something that, in my opinion, and I think in hers too, would actually help, she's, like, a classic perfectionist, an achiever, I mean, she's the best thing since sliced bread, but I said to her what I say to my patients, which is, "Saying no to something means saying yes to something else." Saying no to going to the gym that day because you didn't feel like it is saying yes to the permission to be a blob. And that's healthy.
[00:34:00] I mean, if you say no all the time, like, "No, I can't turn in that term paper," "No, I can't participate in that sporting event," "No, I can't show up at school," that's a problem. But this comes down to what you talk about in your new book about boundaries, knowing what your needs are and having a diverse portfolio of things you can turn to to manage the inevitable stress and distress that life brings.
Melissa: You know, we were, just a moment ago, talking about this idea that it's in our best interest to check in with ourselves and ask ourselves, "What do we need? How are we feeling? Are we hungry? Are we full?" and that we can trust the signals that our bodies are sending us. That applies equally to this idea of setting and holding boundaries. So often, in our lives, we look to everyone else to tell us how to show up, how to behave, what to do, when to be there, how much to give based on their expectations, and again, very rarely are we encouraged to and we're basically never taught to pause and say, "Hold on just a second. What do I need? What would I be comfortable with? How do I feel about this?" And then respawn from that place of self. And that is really at the foundation of my boundary practice. You don't know where you need to set a limit to keep yourself safe and healthy and protect your energy and mental health and time unless you are able to check in with yourself and assess what your own needs are.
Dr. McBride: This is exactly why I think you and I both love our mutual friend Elise Loehnen. She's, like, a Buddha on this stuff. I love the way she talks about and you talk about knowing your north star, knowing what you need from relationships, from food, from the world to be healthy, and then giving yourself permission to ask for it, and then not apologizing for having needs. I think, in the world we live in, men too, but women, in particular, often suffer from this, like, sort of self-sacrifice as a badge of honor, as subjugating our needs, as being altruistic, when, from my own experience and from working with patients for 22 years that always blows a gasket somewhere. I mean, there's anger, there's resentment, and then we'd end up meeting our needs in other ways that aren't maybe so healthy.
Melissa: [00:36:07] Yes. We have been conditioned. Women, and especially moms, have been conditioned by the patriarchy and stereotypically rigid gender roles and religious influences and diet culture to be small, to be compliant, to put everyone else's needs and feelings above our own. We are praised the most when we are not even on our own list, and then when we do ] have a need, we either hint around it because we've been told we can't ask for what we need directly, because that's rude, or if we do ask directly, we are called the B-word, or we're told that we're cold, or selfish, or we have too many rules.
There is this conditioning in society around how a woman and how a mom is supposed to show up, and there's a lot of unlearning we have to before we can start advocating for ourselves and setting boundaries without feeling guilty. Because when I set a healthy limit that is designed to improve our relationship, I am not doing anything wrong, and there's nothing to feel guilty about. But I've got to unlearn all of that other stuff that tells me that I should feel guilty for simply existing and having needs.
Dr. McBride: Amen. Hallelujah. As you might have guessed, I am an oldest child, I am a woman, I'm a perfectionist, I'm a pleaser, and I had to unlearn a lot of lessons that weren't even taught to me by my own family but just by society and living in the world I live in. And what's been "fun," [00:37:30] although, let's be honest, painful as well, is setting boundaries as a grownup and feeling how it's working and not working, and then seeing the net benefit of setting boundaries, whether it's with another person or with habits or behaviors, and then feeling the discomfort of setting that boundary, like, maybe disappointing someone or saying no to something everybody thought you'd go to or declining something else, and then seeing how you're actually really paying it forward for your own health and well-being and actually nurturing relationships by saying no. Because, then, that person knows what your limits are, what your boundaries are. And then, if that person's meant to be in your life, they have a better understanding of your needs.
Melissa: Yeah. You know, boundaries are such a gift in relationships. They create such a sense of safety in relationships, because the other person knows that I am going to take responsibility for my own feelings and needs. So if I say to them, "Hey, I'm really going through something right now. Can we talk?" and they say, "Oh, I can't talk right now. I'm in a meeting,"
[00:38:30] I'm not just gonna wait around for them to be free and dump my problems onto them. I'm gonna say, "Okay, thanks for letting me know, because I respect your boundaries." I really need to talk to someone right now, so I'm gonna go call my therapist. I'm gonna call my mom. I'm gonna call my sister.
If you say to me, "Hey, Melissa, do you wanna do this podcast with me?" and I say, "Sure, I'll do that with you, but I don't really have the time or capacity," and I'm saying so resentfully, and then I'm showing up for this interview, and I'm distracted, and I'm not prepared, and I'm kind of all over the place and scattered, and then you're wondering, "Well, she said yes. Why is she showing up like this? Maybe I did something wrong." No. If I say yes to you, you know I say yes authentically, and I'm going to show up as my best self and my most prepared, and I'm not going to be resentful, and I'm not gonna show up begrudgingly. And if I say no, that's a gift, because you know that I can't give you what you need right now, and you'll go find another podcast guest that's gonna be better than I can right now.
So boundaries are really this clear, kind communication that improves your relationships, and when you can shift and start to see them like that, they no longer feel selfish. They no longer feel like something you should feel guilty for.
Dr. McBride: [00:39:30] It's such a good message. It's so important. It's exactly what I try to teach my kids. Because when you don't set a boundary, you end up paddling in gossip. Your love language can be resentment and, "Wow, look at her. Look at how she's so important." If you don't set a boundary, you end up doing things that go against the grain of your own integrity, and that is intrinsically uncomfortable. And if you're not honoring that discomfort, it's going to show up in another way.
The other thing, on the flip side of that, is there are some times you had to do things you don't wanna do, right? Like, you know, sometimes you just have to turn in the term paper even though you don't want to. You sometimes have to say yes and participate on that sports team because that's the way the world works to be able to make the team. I think the question is, knowing your place in the universe and knowing how to advocate for yourself in a healthy way, you know, that's something you have to learn the hard way, I think, in this world.
Melissa: You know, what I find is that when people live in boundaryless relationships, [00:40:30] they are walking around resentful, they're walking around anxious, they are dreading interactions, they're keeping people at a distance, which hurts the relationship. If my mother-in-law keeps dropping over without calling, and I don't say anything to her because I'm trying to be nice, so I open the door and I'm like, "Hey, Carol. Yep, come on in." And then she comes in, and I'm cold, and I'm short. And I don't wanna visit because it's not a good time, but I don't wanna say so because I'm trying to be nice. And she's like, "What did I do? Like, what is wrong?"
Boundaries [00:41:00] can be uncomfortable. It can be uncomfortable to say, "Hey, Carol. Would you please call before you come over and give us about an hour's notice?" That can be uncomfortable. But what you're doing now is already uncomfortable. You're walking around anxious and resentful and dreading certain interactions, and your relationship isn't going well. And eventually, if you keep holding that in, you are going to explode. And, like, that path doesn't get you anywhere. That's just a circle of doom and unhappiness. And the discomfort of setting a boundary can be momentary but lead to this huge [00:41:30] improvement and expansion of your relationship. And that's the discomfort that I'm willing to go through.
Dr. McBride: I mean, mic drop. Passive aggressiveness is also a byproduct of absent boundaries or wobbly boundaries. We all know when we're being passive-aggressive, and we all know when we're the victim of passive-aggression. And to me, that's a signal that, you know what, it's time to be honest about what's happening here without blame or shame, but just name and own your part of the boundary that was broken. Say, like, "Look, I realize I showed up at a time that was not convenient for you. I hope that next time you just let me know if it's not a good time," or "Hey, I think I might have asked you a question that made you uncomfortable. My bad. So sorry." And then let them talk, right? Just being honest and authentic. And that's a tall order in the world we live in.
Melissa: It is, especially, again, because women, especially, are taught to talk around everything. We're not taught to be direct. We're taught to hint and to hope that people read our minds, and then we get disappointed when they don't do the thing that they didn't know they were supposed to do. And then it just goes back and forth and back and forth, right, and then you end up in these fights where, like, your husband is like, "Hey, can I go out with the guys for a drink tonight?" And you don't want him to because you have a million things to do, but you go, "Sure." And he thinks you don't mean it, but he doesn't really wanna hear it, so he just leaves. And then he comes home three hours later, and you're in full-on rage mode. And you're like, "How could you go out? I really needed you home." And he's like, "You said it was okay for me to go." And I can't tell you how many times in my past lives those cycles had [00:43:00] repeated until, finally, I was like, "Oh, clear communication is kind." And if everyone just said what they meant, relationships would instantly get 78% better.
Dr. McBride: Like, that little story resonates with me 100 times over, by the way. Anyway, it's all so healthy, and these are sort of, like, the infrastructure that we all should be thinking about putting into place in our regular lives, because it's like the skeleton we need to be healthy and happy and to be honest with ourselves. What are you working on? I mean, you've obviously reckoned with addiction. You've reckoned with boundaries. You've reckoned with a conversation around food and bodies in a public-facing way and in your own life. What's on the frontier for you now?
Melissa: You know, I tend to take on self-improvement efforts or self-experiments as they come up for me. I'm not a new year's resolution person, so I don't think ahead of time, "Oh, I'm going to work on this this year." Right now, I'm heavily invested in my own mental health, so I typically have, because of my post-concussion syndrome, combined with winter, I typically get really serious seasonal depression. And this year, I don't have any, and so I'm like, "Okay, what am I doing? How can I keep it up? What are the practices I've put in place that are really helpful?"
So I'm kind of really diving into that and making sure that I'm caretaking for my mental health. And then I feel like I'm in a season of work right now where I'm thinking about how can I rebalance my work and my life. I've had a period of hustle where I just put this book out, and that was a year and a half of really intense writing and touring and media. And, like, maybe it's time to rest a little bit more, and how can I incorporate some more rest into my life? So those are two things I'm focused on right now that I think are going hand-in-hand.
Dr. McBride: You're just trying to be intuitive, it sounds like, and not plan for the inevitable ups and downs. And then it also sounds like you're trying to breathe in and consciously note the conditions that allow you to feel good.
Melissa: I build in moments many times a day every single day to check in with myself, "How am I doing? What do I need?" I do these meditations where I talk to parallel timeline Melissa, "How are you? You're doing amazing out there. What have you done to get yourself there? Like, talk to me about it." I talk to 16-year-old Melissa. I represent myself in these meditations where we talk about what she was feeling and what she was going through and, like, where we are now and how good we're doing new. I have all of these built-in sort of touch bases that I learned in therapy and through my own practices, and I'm constantly checking in with myself to be, like, "What do you need? How do you feel? Where would you be comfortable?" I act on those.
Dr. McBride: [00:45:28] I love it. And then I think, as we focus on self and self-actualization, self-discover, and health, and well-being, we then bring that improved self to our parenting, to our work, and to the world, because we can often confuse effort to know oneself and check in with ourselves as indulgent. When I look at it as the opposite, it is a way of nurturing self to then present to other people, because, to me, and I think to you, being other's focus is a way of maintaining meaning and purpose and satisfaction.
Melissa: I am not a people pleaser. No one would ever describe me as a people pleaser. I am a firm believer in paying myself first. When my cup is full, when I am nourished, when I am fed, when I am well rested, when I am happy, when I am taking care of me, I have so much more to give to everybody else in my life. And that giving feels more authentic, it feels more organic, it feels more joyful. I do this for me. But by extension, that allows me to do things for others.
Dr. McBride: [00:46:30] You're awesome, Melissa. And I'm not saying that just so you like me. What I think is so unique about you, Melissa, is that you're not only writing and speaking and talking to people about health, you're modeling behavior and vulnerability and authenticity and the ability to be forgiving of ourselves when we make mistakes. You're walking the walk, not just talking the talk. So I think you're helping people just by being yourself and by sharing your story, which ultimately is, I think, an important way of affecting behavioral change in others. So thank you for joining me. I'm thrilled that you came today.
Melissa: It is my pleasure. Thank you so much for the conversation.
Dr. McBride: Thank you all for listening to "Beyond the Prescription." Please don't forget to subscribe, like, download, and share the show on Apple Podcasts, Spotify, or wherever you catch your podcasts. I'd be thrilled if you like this episode to rate and review it. And if you have a comment or question, please drop us a line at [email protected].
The views expressed on this show are entirely my own and do not constitute medical advice for individuals. That should be obtained from your personal physician. "Beyond the Prescription" is produced at Podville Media in Washington, D.C.
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How often do you think about your skeletal health? Too often, we take mobility, absence of pain, and physicality for granted—that is, until we are sidelined.
Whether we’re nursing a torn ACL, an arthritic hip, or an osteoporosis-related fracture, even temporary immobility can alter our physical and mental health. It can threaten our sense of self.
Health is about more than the absence of pain or disease; about more than just treating the physical symptoms of a condition. Health is about taking a holistic approach to wellness and recognizing that we are the integrated sum of complex parts. Health is about having awareness of data and the stories we tell ourselves, acceptance over the things we can't control, and agency over our life.
In today’s solo podcast, Dr. McBride discusses the importance of caring for our skeleton like we do our cars—taking it to the shop when it breaks down, and providing regular maintenance.
She gives three examples—including herself!—of people whose physical injuries force them to reckon with their health
How do you care for your skeleton? What can an injury teach you about your health? What is the relationship, for you, between mobility and mental health?
Join Dr. McBride every Monday for a new episode of Beyond the Prescription. You can subscribe on Apple Podcasts, Spotify, or at lucymcbride.com/podcast or at https://lucymcbride.Substack.com/listen.
Get full access to her free weekly Are You Okay? newsletter at https://lucymcbride.substack.com/welcome
Please be sure to like, rate, review — and enjoy — the show!
The full transcript of the show is here!
Dr. Lucy McBride: [Intro] Hello and welcome to my home office. I'm Dr. Lucy McBride, and this is Beyond the Prescription. Today. It's just you and me. Every other week this season, I'll talk to you like I do my patients, pulling the curtain back on what it means to be healthy, redefining health as a process of self-awareness, acceptance, and agency.
[00:00:28] In clinical practice for over 20 years, I have found that patients generally want the same things—a framework to evaluate their risks, access to the truth and data and tools and actionable information to be healthy mentally and physically. We all want to feel more in control of our health. Here, I'll talk to you about how to be a little more okay tomorrow than you are today. Let's go.
[00:00:56] [Episode] Hello, everyone and welcome to my solo podcast. Today we're going to be talking about skeletal health and what happens to our bodies and minds when we are out of commission. Today is the final game of March Madness, and I don't know about you, but I am pretty obsessed with March Madness. I love how it signals the beginning of spring.
[00:01:14] I love the friendly competition of all the brackets, and my family's pretty obsessed with the games. I am no basketball aficionado, but I really enjoy looking at the athleticism, the strength, and the grit on the courts. I also can't help but wonder what these guys are gonna look like when they're patients in their fifties, sixties, and seventies, for example, when they've had a lot of overuse injuries and they show up in the doctor's office, perhaps like mine.
[00:01:40] I think it's important we acknowledge we each have only one skeleton that drives us through life, and we cannot trade in our skeleton like we can our Honda or our Prius. We can only take care of it the best way we possibly can. We can only do maintenance. And I think it's interesting. Many of us take our cars to the shop to rotate the tires, change the oil, align the axles—more than we take care of our skeletons or take them into the shop.
[00:02:06] And by the shop, I mean to a physical therapist or other body. Okay, so why does this matter? Why do we need to think about skeletal health? Why do we need to think about injury prevention and why do we need to treat our skeletons at least as well as we do our cars? The short story is this: our skeletal health is foundational.
[00:02:26] A couple of months ago, I unveiled the visual representation of the way I think about patients’ health. I call it the four I’s. It's a two by two grid, and the way I think about health is that we are the integrated sum of these different components, these four I’s that intersect and that really talk to each other all day long.
[00:02:48] One I is information and data. The second I is inputs—all the things we put in our ecosystem. Another I is infrastructure—our skeletal health, the container that drives us through life. And this is what we'll focus on today. And the fourth I is insight. Our self-awareness and our understanding of how our story lives in our body.
[00:03:08] In this ecosystem, I have assigned an entire quadrant just to skeletal health. That is because our skeletons are essential and foundational to our whole health and the way we move our physicality directly affects our medical information. It also affects our insight and self-awareness, so it's essential that we care for the bones, the muscles, and the connective tissue that carry us through life.
[00:03:33] When these systems are going well, we tend not to notice. When we're walking, jogging, swimming, lifting our grandchildren, putting luggage in the overhead compartments and playing bridge, knitting, gardening, and living our lives without any discomfort or limitation, we tend not to notice. We tend not to pay attention to our skeleton.
[00:03:56] We end up taking it for granted and thinking it is going to be there for us whenever we need it. But guess what? Every now and then we blow a gasket. Every now and then the muffler starts rattling before we even blow the proverbial gasket. And what I see in my office is people who are experiencing pain, discomfort, limitations in their range of motion, limitations in their quality of life and their ability to do the things they want to do.
[00:04:22] And in the case of people who have exercise routines who are managing their cholesterol or their heart health, or their mental health with exercise, being sidelined has major, major consequences. It affects our physical health, our mental health. It can affect our sleep, it can affect our whole sense of self.
[00:04:39] Let me give you three examples. I have a number of patients who are student-athletes. Either they play high school sports or college sports. And you know, these young athletes are very accustomed to being strong, fast, nimble, and not limited in their ability to perform. And so when an injury happens, It can be devastating. Not only can they experience pain and disability, they can also experience a crisis of identity. Particularly as kids tend to specialize in sports earlier and earlier these days, their identity can very much easily get wrapped up in their sport and their performance. I have a patient who's a young woman who plays collegiate soccer at a very high level, and when she tore her ACL—which is an important ligament in the knee—in her season, she was devastated.
[00:05:26] She was experiencing quite a lot of pain after her surgery and was having a difficult time rehabilitating her knee. Unfortunately, the orthopedist was giving her more pain medicine—more Percocet—and that was making her feel more blue, more disconnected, and she came into my office wondering what to do.
[00:05:43] I'll give you a second example. An 80 year old patient of mine broke his femur. The femur is the thighbone, and he broke it because he fell and he has osteoporosis. Now this man was an incredibly proud man. He'd had an extraordinary career doing diplomatic work overseas and he had taken great pride and joy in caring for his beloved wife who had died three years prior from Alzheimer's. Mobility to him was not just about getting exercise, which he was good about doing to manage his heart health. It was also about socializing with his friends. It was about playing cards with the guys once a week. It was about taking his dog for a walk every evening and looking at the bench and the tree where he and his wife would sit every evening.
[00:06:26] In other words, mobility is not just about exercise. It is about our daily activities, our daily life, our daily ability to function. When he came into my office to talk about the upcoming surgery for his femur, he was noticeably distraught. He wasn't in pain physically, he was in despair over his loss of independence and sense of identity.
[00:06:48] I'll give you a third example, and it's me. When I was in college, I developed depression. I didn't know that's what it was at the time, nor did the myriad doctors I saw for the various physical symptoms I brought into them. In fact, they thought that I had things like giardia or an autoimmune disease instead of just asking me, are you okay, and basic screening questions about mood and anxiety and stress. One of the solutions that was suggested to me for this mysterious disease that no one could name, and for which I had no vocabulary to discuss, was running. And so I began running in college and running made me feel better. Running made me feel really good.
[00:07:25] In fact, running in retrospect was providing me with dopamine. It gave me pleasure and joy and some sense of relief from this uncomfortable feeling I was experiencing. But the problem was, guess what? When you only run and you don't do stretching and you don't do any other activities, you get injured. And I did. I developed tendonitis in my knees and I couldn't run, and guess what? I got depressed.
[00:07:46] The point of these three anecdotes is that our skeletons matter not for the reasons we often think. Most people understand that exercise is good for us, that it can help prevent everything from dementia, depression, and diabetes. And indeed I spend a lot of time in my office trying to help people exercise in ways that are sustainable and realistic for their lives. But the reason I so commonly emphasize movement, structural stability, structural integrity of our skeleton, is not just because exercise is cool, exercise is good for us. It's because we literally need our skeletons for our identity, for our mood, and for our ability to function. So when I'm talking to a patient about their skeletal health, I'm not simply saying exercise is good for you. Go do it.
[00:08:33] I want to know the why, the how, and the what. I want to understand what kind of movement gives them joy, what gives them pleasure, and what limitations in mobility they have that they might not even have identified? What are the things in their life that they live to do that requires skeletal mobility and flexibility and strength? Let's think about exercise, not just as a way to fit in your jeans or to run the next marathon. Let's think about it as a way to move through your everyday life.
[00:09:01] My other question is this—What hurts? What is your body telling you about what needs to change? I need to know if you're experiencing pain in your low back, because that may be a signal that we need to work on tightening up your core muscles or your pelvic floor. In other words, we need to listen to those mufflers when they rattle because they are telling us something. They are giving us clues to a part of our body that needs attending. And if I had one lesson for you today, it's to listen to your body. Listen to your skeleton. It matters. So to my patient who's torn her ACL and is recovering postoperatively, I want her to think about exercise in a new way.
[00:09:39] I want her to use this injury as an opportunity to reflect on her identity. I want her to think about—who am I beyond a college athlete? So as much as she didn't want to, she embarked on a project of increased self-awareness. She started doing daily meditation. She started cultivating friendships with people who are not athletes and realizing that, wow, there's a lot more to school and to her social life than playing soccer. Her injury had actually given her permission to explore the ways in which her physicality was central to her identity, but also not sufficient to define her.
[00:10:13] So was there any silver lining for my patient who broke his femur? Well, not right away. After a surgery like that, you're in rehabilitation for many months. You're doing physical therapy twice a week and really building back your strength gradually. As you may or may not know, when you break your femur, it causes atrophy of the surrounding muscles, the glutes, the hamstrings, the quadriceps, and it's a lot of work to rehabilitate those muscles, particularly when you're older.
[00:10:41] So I wouldn't say that there was a real silver lining for this gentleman, but I would say that it forced him to reflect on his mortality in a way he hadn't done. Having to plumb the depths of his grief without the benefit of exercise and socialization as he had been accustomed to since his wife died. It forced him to reckon with a lot of uncomfortable feelings that he had not dug up. And while I wouldn't wish that on anybody, he did tell me towards the end of his recovery from his hip surgery that he had learned more about himself having been sidelined than he would've other. So after his recovery, I reminded him that he was really, really one of the healthiest 81 year olds I'd had in a long time.
[00:11:20] And finally, what about me? So when I was injured and I could no longer run in college, I connected the dots between my physical self and my mental health, and that was a valuable lesson. It was painful because I had no other tools in the toolkit to manage depression. I had nothing. Moreover, I didn't have any vocabulary with which to talk about feelings, and I didn't have healthcare providers to know how to guide me or even to make an appropriate diagnosis. But it did force me to really dig deep into my internal arsenal of tools and to cultivate other coping strategies because I had to, I had no other choice. So what is my point in telling you about these three anecdotes? It is to say that movement, physicality, mobility, range of motion, absence of pain, those things we take for granted until we're sidelined.
[00:12:14] I ask you to do this. Think about your skeleton for just a minute. Take a survey, going from your neck all the way down. What is hurting? What is tight? What is strong? What is weak? What hurts? Taking stock of our muscles, our bones, our joints, and our structural integrity, and taking that moment of mindfulness about our own bodies is step one.
[00:12:41] Step two is the context. What about your skeleton is allowing you to do the things in your life you want to do and what is holding you back? Maybe you have no problems with your skeletal health because you're young, because you happen to be an athlete and because you just haven't been injured. Or maybe you can do the things you want to do because you've worked really hard on pelvic floor muscle tone since you've had three children, and that is the reason your herniated disc is no longer bothering you and that is important to you because when your back goes out, you're unable to live your life. And maybe you're someone who has knee pain and is slowly and gradually limiting your mobility. You're taking the elevator, you're avoiding long walks with your friends, you're taking more Advil and you haven't yet registered that discomfort.
[00:13:26] I encourage you to register what your body is telling you, and then, what is the context? What is that limitation in mobility or in comfort? How is that limitation in your mobility and comfort affecting your everyday life?
[00:13:38] Step three: What is the relationship between your physicality and your mental health? Is exercise good for your mood? Does it help you feel less anxious and more focused? Or do you feel like you are a victim of your own exercise routine such that you're anxious and stressed and dreading getting up in the morning because you know you have to get up so early to go to that class because you said you would. And then ask yourself, how do you feel when you've exercised or you've been in a good routine, and how do you feel when you've been out of a routine or you've been sidelined? What does that do to your sense of wellbeing, your sense of self, your sense of identity?
[00:14:14] And step four: How does regular exercise or just being mobile and living without limitations or pain affect your relationship with food and the content of what you eat? Those inputs in that one quadrant? For so many people, the absence of pain and the ability to move and exercise is directly tied to their ability to eat intuitively and to eat nourishing, healthy foods.
[00:14:38] And step number five: how does movement, mobility, and exercise affect your physical health? Your lab tests, how much better is your blood pressure, your heart rate, your blood sugar, and your weight, if that's what you're working on in the doctor's office. And how good do you feel when your doctor gives you that “hooray! Your blood pressure is so much better and you can attribute it to your exercise routine.” As it turns out, our skeletons provide a map for multiple parts of our lives. They offer us clues about who we are, why we get up in the morning, why we get moving every single day. So let's pay attention to them.
[00:15:15] Let's not wait until we blow a gasket or get sidelined from the court. And even if you're sitting on the couch right now with a big bowl of popcorn about to pop on that NCAA finals game, let's try to treat our skeletons like the foundation to our health that they are. We have one vehicle to drive us through life. Let's care for it like we do our cars and keep moving. Thank you so much for listening. I would be thrilled if you shared, liked and commented on this episode. Your feedback means everything to me. Thank you so much for listening.
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