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
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.
Share this post