Positive Psychiatry with Dr. Rakesh Jain

This podcast provides general information, not a substitute for professional medical advice. Please consult your physician for personalized guidance. Hello, hello, welcome back to PsychRounds, a resident-run educational psychiatry podcast. I'm Dr. Tanner Hewitt, joined by our co-host Dr. Larry Wang and Dr. Bradley Miller. Now on today's episode, we have a very special guest, Dr. Rakesh Jane, will be discussing the increasingly relevant topic of positive psychiatry. Now it's worth mentioning that I had the privilege of meeting Dr. Jane at this year's Psych Congress Elevate Conference in Las Vegas, Nevada. Now we have recently partnered with Psych Congress to bring our audience access to some of their leading speakers and educators. Now Dr. Jane will also be speaking at the upcoming Psych Congress National Conference from September 17th to 21st in San Diego, California, where he serves as co-chair of this steering committee. Now our guest today, Dr. Jane is a highly accomplished psychiatrist. He completed his residency training at the University of Texas Medical School at Houston, followed by a fellowship in child and adolescent psychiatry. Currently Dr. Jane is involved in numerous research and clinical projects in addition to hosting his own podcast titled Positive Psychiatry with Dr. Rakesh Jane. So let's welcome Dr. Jane to the show. But before we do, is there anything else you would like to add to your introduction? Wow. What a nice introduction, Tanner. Hello, and hello, Larry, and hello, Bradley, and hello, dear listeners. I think this topic of positive psychiatry has been so undidiscus. I am delighted to speak about it with all of you. So let's do this. Awesome. Thank you again for coming on the show. So to kick it off, the first question is, of course, what is positive psychiatry as this might be a totally new topic for many of our listeners? And as you mentioned, it's really not part of standard training curriculums. So how is it different from things we might have heard like positive psychology or humanistic approaches? Yeah. And you are right. It is new for us. And it's not just new for you guys. It's new for me. I didn't hear about positive psychiatry until 2013. And the reason why I remembered that particular day, in fact, I do remember the day it was in May of 2013 is because the president of the American Psychiatric Association in his inaugural talk for the very first time even broached the topic of positive psychiatry. And at that time, Bradley, I had been a psychiatrist for, I think about 20 plus years. And I was, let me be honest with you, experiencing a little bit of burnout, experiencing a little bit of what am I actually doing for my patients? That's meaningful. That's, you know, that's good for them in the long run. And positive psychiatry became perhaps my guiding North Star. We'll of course be talking about the components of positive psychiatry soon enough. But it is not positive psychology, even though they share profound similarities. So Bradley, positive psychiatry is in fact the practice of psychiatry that embraces the traditional things we do. But beyond it looks at humanistic values as you talked about. But also the whole notion of wellness, not from a psychological perspective, but to include things that are, I would say pretty medicalized exercise, for example, or mindfulness or nutrition, or the very concept of humanism, not to see people as a collection of symptoms, not to see them as nothing but DSM five symptoms walking around the streets of America. But as humans with real passions and real goals, who yes, they unfortunately do suffer from a psychiatric disorder. And what positive psychiatry has done for me, Bradley, is rejuvenated me in terms of the practice of traditional psychiatry. But far more important than me is given my patients a new way to look at themselves, how to partner with their psychiatric illness and what ultimate goals of treatment are to be created by the treatment team. You, me, patients, others and positive psychiatry offers me a profoundly valuable way to rethink my patients' goals and desires and to move them in the right direction. Yeah, I think that's an amazing intro. And I think the also you're mentioning of your burnout, I think that's going to be really valuable for a lot of us and our listeners going forward in our career and kind of where we can focus with patients to avoid that or resist it. Actually, I kind of wanted to ask because I know that at APA this year there was a big focus on lifestyle and wellness in those tracks. Are there any big takeaways from there as far as positive psychiatry or like updates that you would want to make sure you bring to the forefront before we get into the rest of our topic? Was there with you at this year's really cool American Psychiatric Association annual meeting? And here's a plug for that meeting. People, I'm talking to your colleagues, your residents, listeners, your medical student, listeners and others. Attend meetings. Attend meetings. It's easy to avoid them and attend lots of meetings. And you're right at APA. There was a reemergence on the focus on lifestyle medicine, which I find to be very helpful. Though what I don't like about it Bradley is one small issue, which is the integration of that into mainstream psychiatry. I think I found lacking. It was almost as if we have two side by side interventions, but positive psychiatry doesn't look at it that way. It looks at it more in a vertical fashion, which is we will respect traditional psychiatry. Patients have real symptoms, real impairments. We have real tools, medications and psychotherapy to reduce their symptoms. But what positive psychiatry does, it gives two important parties, patients and their clinicians a brand new way of doing more than traditional psychiatry. So I'm just like you, I found the APA to be very positive. Forget the pun. And I'm very much hoping going forward, they will change their lingo because language matters. They would change the lingo from lifestyle practice of psychiatry into positive psychiatry. I actually want to jump in here because you said something really interesting that it's not a rejection of traditional psychiatry. So that kind of makes me think of the two models that come to my mind more of a saluteogenic or a wellness model compared to the standard disease model of psychiatry. How would you explain the pros and cons, is this like emerging of the two? Could you walk us through that? It, oh wow, a great question, great question, Tanner. It is better than merging of the two. It's actually building of the two. So they stand on each other's shoulders. So the more you practice positive psychiatry, the easier it becomes to help patients with the traditional, I'm using air quotes right now, that traditional psychiatry needs, but the reverse is equally true. The more as a traditional approach that we clinicians have to take with our patients, the better it is to help them if you incorporate elements of positive psychiatry. Whereas I said two different key participants in the dialogue patients have, which is the clinician and the patient. And Tanner, we should never ever forget, even though it's taken me a good 31 years to appreciate this. We are medicine. We are part of the healing process and when we are impaired and sadly it only takes, and I've got a little bit of bad news for you three as you're finishing your residences. The easiest time, so if your professional career is actually now, even though it probably feels, God, look at my call schedule, look at these charts that have to finish. Let me break some bad news to you and then I'll give you some really good news. The bad news in some ways is this is going to be by far your easiest time. Your hardest time is the first five years of practice. And in that five years, you will decide consciously, subconsciously and unconsciously what kind of clinician you will be forever. And that decision point very often is whether you did or did not incorporate positive psychiatry in your interactions with patients. We often think of burnout as happening in people who in their 40s or 50s. I'm seeing so many people in their first and second year of not residency training, but in practice, whether they're working in VA setting or they're working in private practice or group practice, they're reporting, is this all I'm here to do? Is to stamp out depression and stamp out anxiety and panic attacks or am I here to help human beings? So, Tanner, I wanna circle back to your original question, which is, are they collaborative or are they additive? And I would say neither. They're in fact synergistic. Tanner, let me just expand on that a little bit. I sometimes have the pleasure of meeting clinicians who are in their mid-80s, late-80s, and two gentlemen I have met and one lady I met, they were well over 90 in practicing psychiatry. And of course, as someone who's not quite their age yet, I wanted to find out why? What is that spark? And that spark wasn't that they figured out re-sacrificing a ecology or the right ICD code or how can I get better reimburs for X, Y and Z? It really was elements of positive psychiatry that they had incorporated innately into their practices. Now, they didn't have the vocabulary in that they called it positive psychiatry, 'cause that's something we just, you know, in the last 12 years have come up with. But I'm wondering, should we let people struggle through 60 years of their career to get to, if they're lucky, discovering positive psychiatry? Or could we start talking about it today, like we are gentlemen, and alert our colleagues that if you start adding positive psychiatry thinking and practices in your everyday life and everyday work, you're in for a treat for the rest of your career. - I really like what you said about how we're not just focused on reducing symptoms or trying to help the patient as a whole. I think something else that contributes to burnout, at least personally, what I've seen is that there's kind of a fundamental disconnect between what the patient wants and what the provider is looking for. So I'm gonna look, I'm gonna actually reference a 2015 study. So this was actually shown to me by Dr. Roger McIntyre, who was a previous guest on the show. So in this study, it was found that physicians were primarily focused on alleviation of depressive symptoms, whereas patients focused on restoration of positive affect. So getting into more specifics, the aspects focused most on physicians were negative feelings, blue mood, despair, anxiety, feeling down, depressed, or hopeless, whereas patients, what they were most interested in was number one, to what extent is life meaning? Number two, how much are you enjoying life? And number three, how satisfied are you with yourself? So it seems like they care more about getting well and improving psychosocial functioning rather than just reduction of negative symptoms. And I think maybe a part of the problem is some of the scales we use in standard psychiatry life, when we're doing RCTs, we're using things like CamD, Majors, focusing on reduction of negative symptoms. But do we have any scales right now that do the opposite? Like measuring change in positive qualities like resilience? Or should we be developing more of these scales? - I love your question, Larry. I could hug you right now, which by the way, is part of positive psychiatry. People should hug more in psychiatry. We don't do that enough, but your question has five or six different elements. And I think it's worth our time and our listeners' time to break it down. So first of all, I know exactly the study you are referencing and that Roger McIntyre referenced for you. How interesting, I just spent yesterday, the entire day with him. And we were talking about a hundred different things, but this topic is also near and dear to his heart and to my heart. Roger, let's use him as an example, is one of the foremost paths will be in the top two or three most influential psychiatrists in the world. And for him at his stature, to be talking about positive psychiatry should alert every resident and medical student listening to this podcast, they better listen to it now. They better start incorporating these thoughts in these practices now, because if a man whose world renowned for psychopharmacology is saying there's a disconnect between us and our patients, he is right. So that paper has been profoundly influential in my career. You might in speak a note, post a link for your readers to it. And he's not the only one, that paper is not the only one that's looked at this issue. Somebody by the name of Mark Zimmerman, who I don't know if you interviewed him yet. He's from Brown University, if not, I'll make an introduction. He is also a psychopharmacologist and he just like me, maybe 15, 20 years ago, realized there is a disconnect. And the question is, who's the real client here? Is the DSM your client? Or is the patient your client? And I would say this both are our clients. So the list that you talked about Larry, that patients, in fact, rank improvement in psychiatric symptoms, number four, and the list of most important things, psychiatry ranks at number one. But if you flip it around, if you keep looking at the list you talked about Larry, if you look at where clinicians rank wellness, it's way below. And I think the issue is what you said, which is our training, our Bible, so to speak, has been DSM, which is entirely disease focused. That's its job. The training programs, their job ought to have been to actually focus on the patient. So we forgot to do that. We became very disease oriented and our scales don't help. You're completely right. So let's do this. Let's kind of do a quiz amongst us. If I had a PHQ9 score of 20 today, and you were my doctor Larry, I think a goal would be to drive my PHQ9 to a zero. And I would offer you an applause. Thank you for doing that. Here's the problem. A PHQ9 of zero still does not tell you anything because not one item covers it about my resilience. About my happiness, about my optimism, about any of the traits that I deeply care about as a human being. So the fault isn't that clinicians, the residents, the medical students, it is indeed the scales. It is indeed DSM. So we need to literally Larry recreate our way of looking at psychiatric illnesses. And here I wanna take a quick diversion into talking about hypertension. So if I come to see you because I have hypertension, you take my diastolic and my systolic blood pressure reading. You don't say, you know, I'm a diastolic blood pressure clinician, but in psychiatry we only measure illness. We don't measure positive traits. We just don't because we were never taught to do that. So about 15 years ago, I changed my practice. I started doing both systolic and diastolic. So I did PHQ9. I love that scale, by the way. But I started incorporating another scale. I would like to introduce to you gentlemen and to your listeners in case they don't already know about it called the Hu5, W-O-5. Obviously based on the name, it comes from the World Health Organization. It's available in over 30 languages. It's free obviously. And I was astonished Larry. As to how many patients I thought were doing well because you know the scale told me that and the questions I would ask them, well, there were a reflection of the scale. It was a reflection from the DSM. The scales were doing well. The patient wasn't doing well. But then I would see deficits in Hu5. The scores would be too low. And then I would start exploring that with my patients, hey, why are you so much better with your depression or your psychosis or your bipolar disorder symptoms but why aren't you well? And almost always the answer was, I had not provided them any guidance. So I set kind of the mark. Our goal is to reduce your symptoms. Patients followed right along. They got there, but they didn't get the benefits they were seeking. They thought this is the best I could do. So the Hu5 for the first time educated me, you really should be talking about and thinking about resilience and optimism and look for reasons why that is low. What is the social health? What is the spiritual health? If they have a religious practice, where are they with that? Can we talk about other elements such as one physical exercise? Have I given them any advice on how to do it rather than. Just offer it as a throwaway comment. And once I started doing that Larry, I got a bilateral improvement. I saw the depressive symptoms reduce further. This was a real shock to me. I thought all I was doing was trying to improve their wellness. But improving their wellness in fact improved their psychiatric symptoms. And the patients were happier. Their family relationships were better. So my advice as I summarize my thoughts on this particular question is for our colleagues, the listeners to kind of retool their thinking. You are just like a hypertension treating clinician. Just like a hypertension treating clinician, you never look at diastolic or systolic. You look at both. To do that, you can use skills. Who five is one of them? There's another one that my research clinic created. It's called the hero wellness scale. H-E-R-O all words are capitalized H-E-R-O. Because when we scoured the literature, we found that for positive psychology and poor for positive psychiatry elements in particular mattered. H-E-R-O. Happiness, enthusiasm, resilience and optimism. I think we by now conducted about 11 different studies in lots of different populations, interestingly, including medical students and law students and business school students and patients with various psychiatric illnesses. We found a wellness deficit disorder uniformly in us. We also found that very quick interventions with or without medications present do in fact improve wellness and that directly led to improvement in functionality. So Larry, what I'm literally asking America to do, American psychiatry to do is something that they already want to do. They want to be happier clinicians. They want to feel good about what they have done for patients. So what I'm asking them to do is not do a heavy lift, but to give in to what's already innate in you. Every psychiatry resident I've ever met in my entire 31 years of being in this profession and having trained for a privilege thousands of residents by now. No one comes into this specialty purely as a profession. They come into it as a vocation and they want to have people. What they don't want to do is just treat symptoms. So positive psychiatry, I think maybe the North Star we've all been seeking for a long time. Yeah, thank you, Rakesh, for going into that. I just wanted to reference the specific questions on the WHO5 so people can get a concrete example of what this looks like. So I just pulled it up and it has one, I have felt cheerful and in good spirits. Two, I have felt calm and relaxed. Three, I have felt active and vigorous. Four, I woke up feeling fresh and rested. And five, my daily life has been filled with things that interest me. And so you can definitely see that it's almost like some of these are the opposite of the PHQ9 questions like what you're saying or things that aren't captured. So yeah, it's definitely cool to see that in practice. I had never heard of that before and something I'm interested in incorporating at some point. So I do want to ask a little bit about an intersection that I feel like might be applicable, which is the relationship between positive psychiatry and something like logos therapy developed by Victor Frankl. So for listeners unaware, Frankl wrote the book Man's Search for Meaning, which speaks about searching for meaning and purpose as arguably the most important thing in life. Frankl explains that essentially everybody is going to suffer. Some people of course more than others, but if you can find meaning in the suffering, it can act as a strong buffer to experiencing depression. Do you see logo therapy as a component of positive psychiatry? 100% yes. So if you're a psychiatrist very much like the statue of Liberty Bradley, it welcomes everybody. It welcomes every thought. There are no bad ideas, kind of thing. So if you are someone attracted to that innately as a healer and Bradley, I hope you notice I didn't call you a psychiatry resident because you're psychiatry resident second. First you're a human being who for whatever reason wants to be a healer. You're using medications and your psychiatry residency to get to that goal, but that's who you are. That's your DNA embrace it. So if that approach works for you and sits right with you, it is the right approach. You know what's interesting? It sits well with me too. Meaning in life is what psychiatric illnesses suck out of it. Psychological illnesses have a profound ability not to create symptoms only Bradley. They have a profoundly strong ability to reduce the human being to their shell. They are empty. We become empty. All we're filled with is not our depressive symptoms, but the complete absence of meaning and joy. Look, you just read the five items from who five, the fifth item is he'donic drive. Is the ability the desire to extract meaning, enjoy and pleasure from life. Well if you look at pH Q9 item one on pH Q9 is anardonia, meaning it focuses on do you have a problem? And just as I'm focused on do you have a strength? We are not a strength, a strength based specialty yet. And I keep saying yet because I have a complete conviction. Once people realize the value of positive psychiatry, they won't see it as new. What they would see it as, oh my gosh, this has always been at my core. I just didn't know it. Now I'm ready to call it what it is and I will embrace it. And what I see happen is residents that speak to residents because I'm lucky enough to teach them. It's almost like like a wilted flower in the middle of a summer. What all they're thinking about is they're called scheduled and vacation and what job I'm, how could they not do that? Have I made the rounds? What fellowship will I be seeking? What job opportunities, all of a sudden their attention, their minds, eyes, shifts into this humanism, this healing and that word healing is touchy feeling in the mind of psychiatry, but is it really? Is that not the whole purpose of what we do? So coming back to Victor Frankel, someone who should know a lot about suffering because history is so very touching. He himself repeatedly reminded us, suffering can be acknowledged and at the same time your desire for wellness needs to be nourished. Why would that not be the right approach to every single clinical encounter we have? And they're in lies the reason, Bradley, while someone like me, I am in my almost in my mid 60s. This is three plus decade in my career. I'm really in many ways, at least if you look at my resume at the absolute pinnacle of my career. And I'm not saying that in terms of bragging, I'm saying that in terms of sorrow actually, that it took me that long because I did not have any mentorship. There was no conversation in psychiatry till well 2013 about positive psychiatry and look, I'm well trained. I've got a residency like you guys. I have done two fellowships. I even went to graduate school on God a master's degree. If you look at my resume, it's sparkly. It's the kind of resume I work for 40 years to develop. But what was missing is I was not a healer. I was a good diagnostician. I was a good medication provider. Perhaps not a healer. And positive psychiatry has given me the direction that I truly want to make sure that our younger colleagues realize that is a different way, which allows us to not reject one thing about positive psychiatry, but to embrace a new approach to helping our patients so they can thrive. We're cash. I want to jump in here. And as you mentioned earlier about getting into the components of positive psychiatry. So what would you define are those primary components? As I'm sure our audience wants to know, how do we use those in our clinical practice? Yes. I really like that. Perhaps the single greatest component initial. element to use when you practice the art of positive psychiatry, and a clinical encounter is curiosity. We tend not to be very curious in our specialty. What we ask are directed questions. So invariably, and you gentlemen can set me straight on this if you think I'm incorrect. We open the door, the patient comes in, or we walk them into the room. We ask a perfunctory question, "Hey, how are you?" We're almost not expecting an answer. Then what do we do? We actually have recorded interviews over the years and years to see how clinical interviews go. We immediately jump into how your mood be, how your sleep, how your appetite, are you taking your medications? What side effects are you having? Hey, your PhD-9 is showing your endimation. Curiosity. We don't have curiosity. We also ask this question very often, don't we guys? Which is, what's not going well? Next time you guys are in clinic, start not that question if you want to practice psychiatry. Ask this question, "Hey, Ms. Smith, I've been seeing you in a couple of months. Can you tell me one thing that was really good happen since the last time?" It is a complete game changer. When you ask the patient because you're using positive psychiatry as your guiding North Star, it's to start with a human element you would with a friend. So Tanner, if you saw Larry after a month or so, I genuinely don't think you will ask Larry, "Hey Larry, what's not been going well in your life?" I just don't think you will. I mean, what will you ask Larry? I think, "Hey man, what's up?" And I think that question almost says, "What's up being what is good in your life?" But for some reason, when we become clinicians, we literally drop the order being a human. We become clinicians. So I really encourage you guys to start with this very first question, or very first opener, which is, "I really want to talk about your panic attacks because that's what you've been seeing me, Mr. Carlos. But can we just do this for a minute? Tell me a couple of things that have gone really well or a couple of things you've done in the last month or so that you really had fun with. And lean into the patient with curiosity because you have no idea what they're about to say and enjoy it. That I think may be, quote-unquote, element number one, which is curiosity about the patient's life. Do not start with illness. Start with the personhood of the individual. Does that sit well with you guys? Because you do that already innately. I do that already innately. The only challenges. My medical training has beaten that out of me. It's almost told me, "You, sir, will kill symptoms and I'm pushing back against it. I want to be a human first and then everything else that follows." The second suggestion I have for you is, never ever lose a single element of traditional psychiatry. So in no shape of form, positive psychiatry is anti-traditional psychiatry. It is pro-traditional psychiatry. It just adds more. So continue doing all of that. And that really helps. It relaxes the people who are your patients, who don't all of a sudden think, "Oh my God, he's been listening to Deepak Chopra and all he's going to do is prescribe or me a pathic stuff for me." That's not our goal. The third thing I would do is narrow your focus on a few elements of mental health that sit really well with you. I didn't say mental disorder. I said mental health. For me, I have landed on hero, H-E-R-O. Now for you, Bradley, because you just talked about what's "Who Five?" You may want to land on those five elements. Whatever you choose, but come up with a language that works for you. You may want to adopt the hero as your north star for the time being, only because it's the one scale in the world that has the greatest amount of data in psychiatric ill patients. So you might want to adopt that for the time being that scale is available. I'll give you a link to all the resources. It's free. There's never a charge for anything that my clinic and my research lab has created. Try it out. And what will happen very quickly within a visitor too is the patient no longer sees themselves as a walking basket of symptoms. And I want to ask a quick follow-up. Is that great? Should there be an ideal patient that we should be on the lookout for positive psychiatry? Is there an ideal candidate? Yeah. I'm going to totally flip that on its head, Tanner. I'm going to address a question in an ask, which is, is there a non-ideal patient for us to offer wellness interventions? Because once we know who's not ideal, then we will know everybody else's ideal. And you're completely right. There are very clear pressing reasons where positive psychiatry should not enter the conversation yet. It could be someone you are bringing into the hospital because they're so psychotic. It would be completely inappropriate, I think, to bring in elements of positive psychiatry or a couple of reasons. It disrespects the acuity of their symptoms. It disrespects the value of positive psychiatry. If I have somebody who's delirious in an inpatient unit, inpatient medical unit, and I'm sure you three gentlemen have had call where on CL service, where a poor patient's really need the delirium controlled. So there are several situations I can think of where that's inappropriate. But I'm going to challenge myself on what I just said by telling you that now have been formal studies looking at patients with schizophrenia. An active symptom phase who still do better when positive psychiatry has been brought in. So while I do believe about maybe 5% of your clinical encounters, a direct conversation about positive psychiatry would be illogical, potentially even harmful. I will say about 95%, 19 out of 20 clinical encounters we in the world of psychiatry have infusing that encounter with these elements of positive psychiatry, which by the way includes anything that sits well with you. It could be humanism. It could be logotherapy. In my case, it often is mindfulness. In my case, it often is adoption of exercise, not as exercise, but as a lifestyle of enjoyment. It could be nutrition, not because it's good for you, but because it's pleasurable to eat right. Any of those elements, I think in those 95% of patients, Tanner, they're absolutely fair game. I will say one quick comment here. It's very difficult to practice positive psychiatry with patients unless we practice it in our own lives. If you both should a patient, it comes across pretty clearly. If you, for example, simply don't believe in religion, let's say your belief system is atheism, to talk about religion is fair game, but to talk about it in the sense that I believe in it would be fake. You never want to be fake. Unless you truly believe that is the approach and you've yourself practiced it, and why would you not want to practice these good things? And it's perhaps better to hold off right then offer it. Well, I just wanted to comment. So just going back to what you said previously, just changing the beginning of the interview can radically change how we approach treatment for our patients. So usually when we ask those questions, we're trying to gather information, but based on how you reframed it, it seems like the interview is not just diagnostic, but also therapeutic. So I really, really like how you've kind of changed away, changed the way we even think about gathering information, because it's not just gathering information, then coming up with a treatment plan like a step wise, but everything can be therapeutic, even the beginning of the interview, it sounds like. Yeah, Larry, and let's take that question and ask ourselves a secondary question. It is therapeutic, but it's therapeutic for who? Who got the benefit here? Usually in psychotherapy, the only beneficiary is the patient, but in positive psychiatry, there are two beneficiaries. It's the patient and the clinician, and I'm increasingly, as I've said, get older, increasingly believing that diet, the patient, the clinician, that diet both need to stay healthy. And these clinical encounters, if we don't think this out, Larry, progressively, if not done correctly, damage our core. So maybe it's, it's like if you don't wear the proper shoes, no big deal when you're 25 years old, but you're partly just taking a hit and prematurely you might develop osteoarthritis. But if you strengthen the muscles around your knee, you could have your knee joint for the rest of your life. I'm using that as a metaphor to alert our colleagues, alert you, alert myself. It's not, it's like leaving cash on the table. Why can't this encounter you have with the patient be meaningful for both parties? And in addition to starting that interview that way, Larry, you might want to think about closing your interviews with the following suggestion. Hey, Mr. Carlos, remember I started our meeting today by asking you two good things that happen. Do me a favor. I'm going to see you in a month. When you come back, will you tell me? And this works really well. Tell me two really funny things that happen in your life. And when you come back in a month, tell me you do that. Tell me what were those two things. And Larry, what I just did is not leave the patient with the thought, take your medication. But a thought of humor, which by the way is another very powerful element of positive psychiatry. So in a very subtle way, what I prescribed to my patient is an element of humor based psychotherapy, which is not performative humor, but appreciate a humor. So do you mind if I try that with you, Larry, right now? So for example, let's do it. Okay, I'll do it with all three of you. So Bradley and Tanner, you are a notice too. I just want you to do this for me. So in the last 24 hours, can you cast your mind back and share with me one funny thing that happened in your life? If there is one, and I don't care who goes first, but if you can recall something that was funny. And the very fact I asked you to do that, guys, neurobiologically, I shifted you out of your default mode network. So neurobiologically, I immediately made you cast your eyes backwards not to look at what went wrong, but what went right? I could start. So yeah, okay, yeah, just this morning, actually, before we were recording this podcast, I took my dog. So he's a big almost 90 pound German shepherd now to the dog park. And there's a fence separating the big dogs and the small dogs. So there's a little chihuahua on the small dog side. And my big German shepherd was racing back and forth the fence with this little chihuahua. And I filmed it. And it's hilarious. And because the little chihuahua with its tiny little legs was keeping up for the most part. And now now that I thought about that, I feel much happier. Yeah. Even who else felt happier when you said that? Me. Just listening you to describe it. You engaged. Now let me be a geek for a second. You engaged my venture media prefrontal cortex. I can't help it. Humor automatically shifted my neurobiology. And Larry, we are not going to be meeting each other in a month. But if we were, and if I was to tell you, Larry, next time I see you, just share with me two funny things. What happens is you're not going to start scanning your environment for humor, not just for negativity, so that you can come share it with Dr. Jan in a month. So that was just a quick example of how a positive psychiatry interaction with a fellow human being who happens to be a patient can in fact be very valuable. So either Bradley or Tanner, do you guys want to share anything? That was funny. That happened in the last 24 hours. And let's just play a game here. A Bradley says, I don't remember anything. Nothing good has happened in my life, which you were going to encounter in patients. And what you can say in that situation is, I totally understand. But can I tell you one funny thing that happens? So you are normalizing it and you can say to them, you know, sometimes I also have days where nothing funny has happened. But we got 30 days from now until I see you next, even if you come up with one funny thing, write it down so that we can discuss it next time. Yeah, I was going to say like that suggestion because of course we get patients all the time that have the overall bleak pessimism. You know, I would say that was one of my roommates. I was watching a comedian and I don't know if I could share the full content of the comedy sketch, but a good YouTube comedian that we both enjoy. So that's always a positive experience, I think. Yeah. Good. You do not have to share the content and some patients will say that I can share with you because it was racist, it was off color. And my point to them is, it's not that. The you sharing it multiplies the joy. And just like what you just shared with me Bradley and what you shared with me Larry, interestingly, you're going to carry this through the day. You just are. That's just human nature. These psychiatric illnesses have an ability not to create psychiatric symptoms. They have an ability to reduce our positive traits. And if I'm a high quality prescriber of, I don't know, Eric Pritzell and Fluoxity, I think I have an obligation to be a high quality prescriber of say humor. Or we haven't touched base on this yet. Like, music is a neurobiological intervention of the first order. Why don't we prescribe music? We should. And maybe during some of the podcast we can talk about how over the last 15-7 years I've actually medicalized music intervention as part of my psychopharmacology practice. But humor is a neurobiological intervention. Tanner, do you want to add anything? I'll just, I'll keep it brief, but also a dog owner like Larry and I'm in the process of setting up my future son's nursery. And we had everything I'll put together. And then the second we brought the stuffed animals in the dogs now believe that this is now their nursery. So. Man, an image just popped into my head about your dog's kind of going, finally, daddy Tanner is getting his act to get free toys, toys for everybody. See this humor, just imagine this humor percolating into your clinical rule. Imagine, is does not put down the patient's symptoms? It doesn't tell them that we should laugh away your symptoms. You just don't have good enough humor. That's why you are dyslemic. It tells them their brain has abilities that they haven't realized or forgotten about. And besides prescribing your peroxetine, I can prescribe humor. And gentlemen, that in a nutshell is positive psychiatry. I loved that talk and of course sharing the humor is always fun on a podcast format. But I'm going to redirect a little bit to my last question, which, you know, the nerd and me is going to respond. And I've been reading, it behaved by Dr. Robert Sapolsky, which is a great book for anybody who hasn't read it. But it got me thinking about how the ventramedial prefrontal cortex is very pro-social, like what you're saying. That's going to be a big part of this. But also you talking about the default mode network made me think about meditation. And I know that you've talked about meditation a lot in other interviews. And I was wondering if you would give our listeners and us some practical advice about how to start utilizing this intervention with patients. Because even people who are interested, I find sometimes there is that activation energy barrier or confusion about meditation. Yeah, yeah, use me as a post-to-child Bradley. I researched and talked about meditation for 20 years before I started doing it myself. And the barrier was I was intimidated by it. I was intimidated by it. So how did I overcome that hesitation and maybe are there lessons for others to incorporate? And the answer is absolutely yes. So a little bit of background. And here's the background. The number one cause I genuinely believe and the data supports me. Why people? fall back into the psychiatric illness, in particular, major depression, is not a depressive event, which is kind of a weird thing to say. I think it really is rumination about that event. So I think psychiatry, we get it slightly wrong. We try to stamp out every episode of psychiatric illness, rather than stamp out what creates them, what is the precursor to them and the precursor to them is two things. I believe and let's see if you gentlemen agree with me or not. First is rumination followed by catastrophization and that one to punch knocks people down and meditation and I should rephrase that mindfulness, which is not quite meditation. Mindfulness alters that for the better. So what is mindfulness? Maybe I can share that with you Bradley real quick before we jump into how one can overcome that initial inertia you mentioned. So mindfulness is as simple as paying attention consciously, willfully without ascribing a meaning or emotion to it. It's a bit like sitting by a river that's flowing fast without putting a meaning to it, but by observing it. And we have studies looking at 60 seconds, 60 seconds of intervention, mindfulness interventions, producing both neurophysiological changes for the better, but also mental health challenges. So what is the barrier? If this is such a useful thing, why aren't we doing it? I think the number one barrier Bradley has been, I won't do it right. I'll screw it up. I can do it right. And what helped me is a friend of mine telling me that's a wrong question because the right question to ask is, can I do it wrong? Is this such a way of screwing up meditation? And the answer is no, because to watch your mind be distracted is in fact the practice. The whole practice is to watch your distracted mind and to not ascribe judgment to it. So in a minute, I will give you a website, my website, where I actually in fact have created a workout schedule. So if you're a brand new brand new to meditation and you're intimidated by Bradley, I've created a single page flyer with meditations I have recorded. So the meditations already exist on the website. All you got to do is follow a one week program. And no meditation is longer than 10 minutes. If you want to listen to it while walking, and of course you have your eyes open, you're walking your dog, Larry and Tanner have a dog or have dogs. Guess what? Do it. You don't have to do it with your eyes closed in a lotus position on top of a mountain. It is absolutely unnecessary. And maybe I'll just say one other thing, maybe two other things to allow me. Number one, you cannot screw up a mindfulness practice. To stop ascribing a grade to it. Two, and this may be as valuable as the first advice. If you meet your distracted mind, if you meet your mind and your thoughts that jump all over, congratulations. That's how it's been since the time you were born. It's just now you're meeting it. That meeting is mindfulness. And then after that you will develop a practice. So Bradley, what I've learned is lecturing to people on this topic is absolutely useless, giving them a treatment plan. Again, I'm using air quotes has been far more successful. Well, thanks for that. And since we're on the topic of meditation, I kind of want to switch gears a little bit, but stay on the same topic and talk about the fact that I see a lot of concepts from Eastern philosophy and positive psychiatry. And you know, me being of a Chinese background myself, I know that there's many ethnic and cultural minorities that don't like a biomedical or disease model of mental health. And so for me, I feel like positive psychiatry is kind of like a bridge almost to connect east and west. I wanted to hear about your own thoughts and experiences as well. So because I know I think you're the health Asian background. Yes, Larry, I do. I'm originally from India, but I want to a quick confession. I left India when I was 23 and I rejected everything about my culture. I wanted nothing to do with it. I had in my youth, you know, young people, right? I said, nope, this is all BS. This is all illogical. And it wasn't until I turned 40 some did I say, okay, nothing is BS. It's just a matter of taking the best of whatever culture there is. And I think you nailed it, Larry. People from our Eastern traditions do have a world view of the biological model that challenges our treatment plants, offering this approach to them really works well. But the same time I want to tell you this, the Western mind and people who are raised in the Western traditions really are hungry for more from us. So I have often told my patients the following, Eastern philosophies and Western philosophies are just two different ways of looking at exactly the same problem. And you and I need to be why these let's take elements from both of them. Because if we incorporate both of them, your symptoms will diminish, which is an important goal. If you're having horrible insomnia, no matter how much I talk about positive psychiatry, you're still going to be suffering. But if I control you insomnia, I'm sorry, the humanistic suffering is still going to continue. Let's incorporate elements of both right now. And we will change the ratio as we go by. It has been very successful, Larry. So I've been using this approach now, as I said to you, gentlemen, for about 12 some years. And I keep waiting for the patient who tells me, you know what? This doesn't make sense to me. I've been waiting for that first patient. It still hasn't happened. You have the inquisitiveness that you three have offered. What do you mean? Positive psychiatry. Have you been doing negative psychiatry so far? And after Russian and say, no, no, no, it's a traditional view of psychiatry. It has been very helpful to you. Many other patients, maybe even your family members and your friends, but it is not enough. I'm just wanting to incorporate that. So if you're a patient of Cambodian descent or Chinese descent or Indian descent or Western European or South American, what this has done for me guys is taken away this notion that I'm open quote, pill pusher end quote, which if you haven't yet encountered that slur, you will, I promise you, they'll either say it or they will feel it, but once you bring positive psychiatry into that clinical room, all of a sudden, all of a sudden, you are a clinician, a fellow human being who has expertise in medications, but you have real expertise in humanity. What do you think, Larry? Do you think I'm on the right track? Oh, absolutely. I mean, I've been called pill pusher or I'm a young resident still, but I've been called I've probably got called pill pusher maybe like once a month on average. So I definitely think your perspective offers a more balanced approach to treatment, a more humanistic approach that patients like. Yeah. Yeah. And it used to hurt me. It used to hurt me when when people call me that until Larry, I became a patient with say hypertension and I've got to what my doctor calls borderline diabetes. So my glucose tolerance test is suboptimum. And what I encountered Larry is the, is the traditional medicine view from the other end as a patient. And I did not from my healthcare providers get what I think they should have is a conversation about exercise and nutrition and sleep and all the things that I genuinely think I needed. And I don't fault my clinicians. That's been their training. So you know what I said as I left the clinic is pill pusher. I said that in my mind towards my own clinicians. And in psychiatry that risk is even greater. So I think you and I, the three of you and I are making a very convincing case. I hope that our listeners will appreciate that the true service of our patients is suboptimum. If all we all is traditional psychiatry. But I want to hurry to add the following. If all we do is offer positive psychiatry without taking advantage of what traditional psychiatry has to offer, I think we're as damaging. It's not this or that. It really is this and that. Thank you, Rukash, for walking us through that. As we draw down to a close here for today's episode, is there any final remarks you'd like to make? I'll start out by thanking you three for allowing me to talk about this topic. It would have been so much easier to just talk about seven, tell me, and a pick a disorder. You know, I'm very fluent in that language. It's so easy. It's, you know, it's second language. Positive psychiatry requires me to engage. Well, a whole lot more of my mind, of my brain. I just want to make sure that our listeners appreciate that I am no shape of form asking them to reject what they are already doing. Congratulations. Do it better. Become a better psychopharmacologist, become a better therapist. Do that. We need you guys. You are residents to be the very best of what you can do in traditional psychiatry. I will stand by and applaud you as you pursue your fellowships and your trainings and all that. What I ask if you do not listen to me, but listen to your own core. And I have a thousand percent belief that your inner core is not a psychopharmacologist. Your inner core is a human being who feels the plight of your fellow human beings and you want to help through the lens of psychiatry. Good job, guys. Positive psychiatry will be good for your patients. The evidence is striking. It'll be good for your patients. And the evidence is very rapidly emerging. It'll be good for you. There's absolutely nothing wrong with being selfish in the right way. So my prescription of positive psychiatry is bidirectional. It's good for our patients. It's good for us. It's free. No managed care to call nothing to do. It's an attitude. It's an approach. Try to open your interviews with patients on a positive note and on a positive psychiatry note. And then let's see how things go. So thank you very much for this awesome opportunity to converse with you three gentlemen. No, thank you. Absolutely for coming on and talking about positive psychiatry with us. Rekesh, is there any way our listeners can stay in touch with your work? And I guess did you want to plug your own podcast? I think your podcast is all they need to listen to. I don't want to necessarily plug it other than to tell them expand your vocabulary to your colleagues. So one of my favorite podcasts that I and Dr. Chepki started just a few months ago is called Psych Congress Family and Friends. And we cover a lot of tradition psychiatry and a lot of positive psychiatry as well. Look at the title. Instead of saying for psychiatry, we are saying Psych Congress Friends, which is positive psychiatry and family, which is positive psychiatry, right? Togetherness. I would love for folks to even go visit my personal website, which is Jan Jain, UPLIFT.com. And the only reason why I'm recommending that is because all the resources that are talked about the scales, the YouTube videos on this topic that we have recorded, the meditation, meditations that we have recorded that are available for you and that cheat sheet on how to get started on a mindfulness practice are all there. So it's a resource rich website. So they should do that. But I think they should continue listening to you because you guys are evolving. And I think in your evolution as you bring positive psychiatry into it, actually think the following. Even your podcasts are going to change. I think your approach at looking at, I don't know, schizophrenia. Oh, I heard you I heard your podcast on propanolot, which was by the way, outstanding. Well done. I learned quite a bit. But even propanol for panic, for example, anxiety can be further magnified and augmented and it's effect when you bring in elements of positive psychiatry, just as an example. So wishing you gentlemen in your listeners the very best. All right. So that brings today's episode to a close. We want to sincerely thank Dr. Rakesh Jain for coming on to our podcast. Now if you are interested in attending the upcoming national site, Congress conference in San Diego, California from September 17th to 21st where Dr. Rakesh Jain will also be speaking, we have a special promo code for you. Use code psych rounds, which will be posted in the episode description and we'll give you a nice little surprise discount. As always, feel free to contact us at psych rounds [email protected]. If you're a fan of the podcast, please drop us a follow comment rating review as this helps us reach larger audiences. Thank you for listening. As always, we will see you next time friends and have a great rest of to the week.