Beyond the Prescription – Details, episodes & analysis

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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.

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.

You can also check out this episode on Spotify!

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.

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 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 info@lucymcbride.com.

[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.

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 info@lucymcbride.com. 

[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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[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 line@infolucymcbride.com. 

[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.

You can also check out this episode on Spotify!

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.

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.

[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 info@lucymcbride.com. 

[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.

You can also check out this episode on Spotify!

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.

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 info@lucymcbride.com. 

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. 

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. 

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 info@lucymcbride.com. 

[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.