Embark on a journey through the mind with us as we celebrate the advent of Mind Dive's third season, reflecting on our shared experiences and the profound insights we’ve gained along the way. As the new year unfolds, we warmly embrace the path ahead, filled with compelling discussions on mental health. Our first port of call is a question that's been burning in the minds of many: Can the storied practices of psychodynamic therapy still hold their own in the modern clinician's toolkit? We promise an enlightening conversation that peels back the layers of this traditional approach, revealing its potent ability to bring about transformative change and how it harmoniously coexists with the structured techniques of CBT, DBT, and ACT to offer a comprehensive treatment strategy.
As we unravel the complex tapestry of mental illness, we touch upon the genetic factors that play a pivotal role in conditions such as bipolar disorder and autism, delving into the latest genome-wide studies on schizophrenia. We’ll navigate the challenging but fascinating terrain of genetic predispositions, considering the impact of nature and nurture on our mental landscapes. Our discussion leads us to confront the philosophical implications of free will in the face of genetic determinism, all while maintaining a discourse that is accessible and engaging for our listeners.
We don't stop at the cerebral; we also address the all-too-human experience of burnout, particularly within high-pressure professions. Sharing insights into the systemic and individual factors that contribute to burnout, we emphasize the importance of balancing meaningful work and self-care. We reflect on how the emotional rewards of challenging work environments can sustain one’s passion, even as we grapple with the corporatization of medical practice. Through stories of resilience and the pursuit of joy in our endeavors, we aim to leave you with a newfound appreciation for the art of self-preservation and the courage to seek fulfillment in every aspect of your life. Join us for these candid conversations, bringing light to the shadows and warmth to the soul.
Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!
Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.
Embark on a journey through the mind with us as we celebrate the advent of Mind Dive's third season, reflecting on our shared experiences and the profound insights we’ve gained along the way. As the new year unfolds, we warmly embrace the path ahead, filled with compelling discussions on mental health. Our first port of call is a question that's been burning in the minds of many: Can the storied practices of psychodynamic therapy still hold their own in the modern clinician's toolkit? We promise an enlightening conversation that peels back the layers of this traditional approach, revealing its potent ability to bring about transformative change and how it harmoniously coexists with the structured techniques of CBT, DBT, and ACT to offer a comprehensive treatment strategy.
As we unravel the complex tapestry of mental illness, we touch upon the genetic factors that play a pivotal role in conditions such as bipolar disorder and autism, delving into the latest genome-wide studies on schizophrenia. We’ll navigate the challenging but fascinating terrain of genetic predispositions, considering the impact of nature and nurture on our mental landscapes. Our discussion leads us to confront the philosophical implications of free will in the face of genetic determinism, all while maintaining a discourse that is accessible and engaging for our listeners.
We don't stop at the cerebral; we also address the all-too-human experience of burnout, particularly within high-pressure professions. Sharing insights into the systemic and individual factors that contribute to burnout, we emphasize the importance of balancing meaningful work and self-care. We reflect on how the emotional rewards of challenging work environments can sustain one’s passion, even as we grapple with the corporatization of medical practice. Through stories of resilience and the pursuit of joy in our endeavors, we aim to leave you with a newfound appreciation for the art of self-preservation and the courage to seek fulfillment in every aspect of your life. Join us for these candid conversations, bringing light to the shadows and warmth to the soul.
Follow The Menninger Clinic on Twitter, Facebook, Instagram and LinkedIn to stay up to date on new Mind Dive episodes. To submit a topic for discussion, email podcast@menninger.edu. If you are a new or regular listener, please leave us a review on your favorite listening platform!
Visit The Menninger Clinic website to learn more about The Menninger Clinic’s research and leadership role in mental health.
Welcome to the Mind Dive podcast brought to you by the Menninger Clinic, a national leader in mental health care. We're your hosts, Dr Bob Boland and Dr Kerry Horrell Twice monthly.
Dr. Horrell:We dive into mental health topics that fascinate us as clinical professionals and we explore those unexpected dilemmas that arise while treating patients. Join us for all of this, plus the latest research and perspectives from the minds of distinguished colleagues near and far. Let's dive in. Hello.
Dr. Boland:Hello, can we still say happy new year.
Dr. Horrell:Yeah.
Dr. Boland:I don't think it will. Larry David says no, I think you only get to the seventh.
Dr. Horrell:Oh well, this definitely come. It's currently the 12th Right and it's our first one in the new year, so. I guess we still get the same. This is a recording in the new year Exactly.
Dr. Boland:So that's, happy new year.
Dr. Horrell:And well, to our third season of Mind Dive podcast. Hard to believe. It's pretty wild. It doesn't feel like that long ago that you came with me in my office and asked me if I wanted to be part of this project.
Dr. Boland:Are you regretting that day now?
Dr. Horrell:Absolutely not. This is really one of my favorite things I get to do Correct Because okay, if we were to take stock for just a minute before we hop in, we've talked to some incredible people yeah. Like to feel like I've got to connect with some people who I've revered and respected our field and just like, and also people who I've just met for the first time. You know, I'm getting to know, I'm like, just so.
Dr. Boland:Professor, yeah, today's not going to be one of those days.
Dr. Horrell:No.
Dr. Boland:No, no, that's not true. I am talking to an amazing person.
Dr. Horrell:Not me. Yeah, I feel really privileged to get to do this. And yeah, we were back doing what we did for the first episode of season two. Hopefully, we're going to make this a little bit of tradition, which is, yeah, it's just going to be us today the mail back, just shooting questions. We're, we've we've gathered some, some topics and questions We've done this. Is our second time doing this and I think both times I've been like oh well, now we have to answer these questions.
Dr. Boland:Right, exactly.
Dr. Horrell:As if we're, like, the expert on any of this.
Dr. Boland:Well, I mean, so we should just claim it. Now we're not, but we know something.
Dr. Horrell:We've been doing this, president. That's right. That's got to count for hospitals, that's got to come.
Dr. Boland:That's got to count for some. Yeah, just a PhD, just whatever. You're right.
Dr. Horrell:OK, we know a few things and we're going to cover it, so we're going to do what we did last time. We've kind of both picked a question to focus on and then we'll do one together.
Dr. Boland:And we'll just do it together. Yeah, yeah, ok, and that should, that should run this out.
Dr. Horrell:Do you want to go first?
Dr. Boland:I don't care what was going first mean? Does it mean I get to ask you the question first? Or does it mean I have to like answer first?
Dr. Horrell:You have to answer first.
Dr. Boland:I don't. What would you prefer?
Dr. Horrell:You asked me first, I'll go first.
Dr. Boland:OK, I somehow. I knew if I left it open you would jump in.
Dr. Horrell:And, if anything, yes exactly.
Dr. Boland:OK, this one comes I think it was actually from a patient, right.
Dr. Horrell:It was from a colleague, you got this yeah it was from a psychotherapist who was relaying that they were asked by a patient. This patient was an adolescent, yeah, and this.
Dr. Boland:So this patient had basically look, I'm asking the question now, but I know, but I'm going to, you're not going to say the question. Yeah, I get to do that part.
Dr. Horrell:I will say this came from a colleague and it came from a adolescent asking them this question.
Dr. Boland:Right. So I don't know the motivation of the of the adolescents. I have to put in my own for you. But but it's, here's the question first, and then I'll tell, give you my take on this. The question is actually why would someone practice psychodynamic therapy, which is interesting? I don't.
Dr. Boland:I don't know exactly what they were asking, but I think there is sometimes sort of like a bias, like among some people out there now that that's kind of like old therapy that's not really done anymore, that with all these kind of like third generation new hot therapies that are often like short term type things that sort of are very kind of structured and manualized.
Dr. Boland:And you know that that. You know that why would anyone sort of do the old thing again? And it's sort of, I think I must say, as another aside we'll get to your answer in a second Is that I must say you probably don't know this, but medicine probably reinforces that, because whenever you take like board exams or questions or things like that, it's much easier to write a question about, say, cbt than it is to answer. Write a question Like I'm talking about multiple choice questions, mind you then like a psychodynamic question because CBT, there's kind of pretty clear right and wrong answers and stuff, and plus they have a lot of research. So whenever you see a question of like what's the best treatment for X, you know the answer may well be CBT, which doesn't necessarily mean it's true. It means that that's the one that has the most research.
Dr. Horrell:Yes.
Dr. Boland:But that's not what we're asking you about. So, given all these kind of biases and all this kind of stuff out there and I know you do do psychodynamic therapy, so you see what the right person to ask why would you? Why in the world would you do it? It's a lot of work and you know a lot of time. Why would you do such a thing?
Dr. Horrell:And what I loved about this question was, again, even though it was coming from a colleague, it was being relayed to us from the perspective of this team and that means in my mind, this person's probably not all that interested. I don't want a stereotype, but like the research behind it, but maybe from a little bit more of like a pure place of like, well, why? Why do we talk about our childhood and all these inner thoughts? And I actually think that's such a common question that when I work with people I get asked which is why does this matter? Why would talking about, for example, if somebody is going through an intense moment at work and I want to know about if any of it feels familiar to things in their life and experiences they've had with partners, family, and a lot of times like a reaction I might get from some of my patients is like why would that matter? Why?
Dr. Horrell:are we persevering and dwelling on things that I'm past.
Dr. Boland:So I think we're going to have to do what we always do is and this is going to be hard, but you got to define this psychodynamic therapy. We shouldn't assume everyone knows exactly what that means.
Dr. Horrell:Well, gosh, yeah, that is a tough one, I will say.
Dr. Horrell:I'm going to refer us back to Dr Jonathan Schedler you know his did cover who came on here, but also he you know one of his like really landmark papers as a hope to show that psychodynamic psychotherapy is quite evidence based. He also like lines up what is psychodynamic psychotherapy and ultimately, if I were to be very brief about it again, I recommend people read that paper and or listen to the episode, because he does a nice job. That's a great episode, Probably a little easier than reading your whole paper. But focus there's a focus on the therapeutic relationship. There's a focus on internal conflicts and what goes on inside the person. There is an awareness of and an appreciation of the fact that we have an unconscious and that there are things that are outside of our own awareness that are influencing us.
Dr. Horrell:There is a focus on things like transference and countertransference, as in what comes up in the relationship is meaningful data about the patient and our own feelings and reactions in the therapy to work. Is data about the patient.
Dr. Boland:It's informed from past relationships.
Dr. Horrell:Yes, and often what gets people stuck. So when we think about psychodynamic psychotherapy and I will say, when I was in grad school and I took my course on psychodynamic therapy, I remember having a lot of hostility towards it myself, really, and actually my teacher who taught the class at Earl Bland is someone I've wanted to invite on the podcast, so maybe that'll be a 2024 possibility but I remember being pretty hostile towards the concept because I thought, hey, this is a therapy for only wealthy people. Not everybody can come into therapy for years and I thought it's something that is also not necessarily going to be what's most important for our patients who are acutely struggling. But I thought, if I have a patient who's in the midst of a crisis and I'm like, let's talk about your parents, it would feel like that seems almost like comic book stereotypical psychiatry.
Dr. Horrell:Yes, and ultimately I think that there's a lot of problems. This is a little critical, but there are critiques one can make about Maslow's hierarchy of needs. I won't get into that at this moment, but I do think there is something important to be said about the reality that it is really hard to attend to deep internal conflicts and things like our history, our trauma, our pain, our relational templates when we are not housed and we don't know where it's coming from.
Dr. Boland:And we don't have our basic needs.
Dr. Horrell:So again, I stand by some of that, but I actually what I think I've learned is that and this is why, ultimately, I would say I'm psychodynamic in orientation but I'm quite integrative in practice, because I think meeting the patient where they're at and trying to help them with whatever is most pressing is the most important.
Dr. Boland:Definitely. We should add that it's informed by psychoanalysis Right.
Dr. Horrell:Yes, yes.
Dr. Boland:And the reason we don't just call it psychoanalysis is because the technique is somewhat different.
Dr. Horrell:Yeah, exactly.
Dr. Boland:Yeah, that's rigid, I imagine.
Dr. Horrell:The way I think about patients often is in regard to a psychodynamic frame of thinking about what are some of the things that go on inside of this person and how can we make those a little bit more aware and do some non-judgmentally? I think that's another piece.
Dr. Boland:I would definitely say so if I were to answer this question yeah, but I'm curious now because you kind of put it out there that you weren't you didn't start interested, so this wasn't just when you came in. So I'm curious what changed your?
Dr. Horrell:mind. Oh yeah, and people who I went to grad school with, who were in my cohort, like it would definitely we have laughed about the fact that I ended up somewhere like Medingar that has this tradition of being more psychodynamic informed, because I was like a CBT or I was stuck.
Dr. Horrell:Interesting and again, I find a lot of value in CBT. I think that there are definitely important skills and ways of helping people have these tangible ways of coping that many patients have clearly found in crises, CBT of course being cognitive behavior therapy and so much more structure, yeah.
Dr. Horrell:And again, I think that what I found was that, because what I, if there was one thing I found myself gravitating towards my training and my career so far, it's people with complex experiences, usually including trauma, so people who are hurting and they've had, again incredibly painful experiences that are complicated and nuanced. And ultimately, one thing I like to tell my patients and I really believe is like I don't treat diagnoses because I never met a diagnosis. I treat people, I work with people. Diagnoses are only ever connected to a person with a story, and what I found over time was that I really wanted like the driving motivator of wanting to be more involved in a kind of cognitive, behavioral and the many waves after that kind of approach was I really wanted to help people feel better and what I found was that, of course, like a lot of those tools help people feel better, but this particular population I was interested in, there was a necessity of looking a little bit deeper and that feeling better oftentimes meant feeling worse. First, in that there was a necessity of looking back and looking at some of the stuff that has happened in life that has developed and built the templates in which this person's bringing into ongoing relationships and experiences. Maybe and I'll end with this analogy because I find this very useful in helping perhaps this teenage patient and any other person who is wondering why would I need to do this part of looking back? I want to just focus on the future and getting better.
Dr. Horrell:This is an analogy I often give. So if you broke your leg as a child and you didn't get the support and care and healing you needed from it, your leg would still mend, your leg would still. The bone would find a way to heal. It just might not heal correctly and perhaps this person then is able to walk. But maybe they're not able to run and perhaps they experience a lot of soreness and they experience a way in which they don't. They can't run, they can't keep up with other people, they get tired easy, they're sore, and so they realize I really want to get this fixed. Maybe I'm at a place in my life where I can get this looked at and healed appropriately. You know what I'm realizing. I'm giving this analogy to a doctor, so you're going to tell me if I get any of this wrong.
Dr. Boland:Well, I think I knew where you're going and it's going to be painful.
Dr. Horrell:Yeah, and how do you? How would you? How do people heal a bone that's been mended wrong?
Dr. Boland:Right, oh Well, they have to break it.
Dr. Horrell:They're going to have to re-break it, yeah, and they're going to have to, they're going to have to get in there, re-break it, and so a person might have been sore before, but now, as they're healing from that, they're not like a, they're even more in pain, and I think so often that is how treatment can feel, as I came into feel better and now we're we're dredging up stuff and going into stuff that's making me actually feel even worse.
Dr. Horrell:But so often for the sake of healing something that's been there the whole time, that needed to be healed, and for the sake of feeling better, of course I want my, want my patients to feel better in the long run, and so that's my little analogy that I use to try to help make also make sense of the fact that, especially as people start doing intensive, especially trauma or attachment treatment, they often feel like I feel worse. This is worse Now. I'm not only depressed, but I'm like grieving and feeling all this stuff and just reminding people that that's so much a part of the process and how people feel better.
Dr. Boland:Yeah, I mean for me I'm a primatist, right? I mean I'm a fan of psychodynamic therapy because it works.
Dr. Horrell:I was going to say how did how? Did you like my answer? I liked it, I sold you.
Dr. Boland:Yeah, yeah, well, yeah, might as well. Probably you know I'm probably already by a story, but yeah, I mean it works and also treats some very, very complicated people who were very hard to treat.
Dr. Horrell:And as Dr Scherler shared in his episode but I've definitely seen my own work is that, especially for folks who have struggled with other types of treatment which are often the kind of folks who come here they failed out of other therapies. They find themselves in cyclical patterns. What I've noticed is that this approach really ends up helping people feel like they're making changes that are really sustainable, like there's a longevity to the work, that we've gotten at the core of the conflicts that needed to be gotten at, rather than focusing primarily on the symptoms.
Dr. Boland:Yeah, and I'd say, in fairness to CBT, I think Aaron Beck and people like that, who you know, who, aaron Beck, of course, was the I was going to say discovery. He developed it, he found it in the record. He found it, yeah, exactly, it was an ancient old book. But I think he'd be the first one to say they're not antithetical, and he you know they draw from similar principles. Actually, there's just different approaches.
Dr. Horrell:I can tell you I use plenty of DBT Act, CBT skills when I'm working with folks who are not like they are. Yeah, seems like they're in the thick of coping with, like their nervous system going off the charts. They're, you know they're struggling with anxiety like these are.
Dr. Boland:Well, it seems to me many expert therapists kind of avoid that kind of argument which one's best or something like that anyway.
Dr. Horrell:Well, thank you, I'm hearing you calling me an expert there.
Dr. Boland:There we go.
Dr. Horrell:Well, time for you to be an expert for.
Dr. Boland:Okay, sure, you could have gone on more, but okay, well, I think we covered it. That's how I'll try to be brief then too. I don't think I was brief.
Dr. Horrell:Honestly, I don't see any sort of clock for what we can't tell, but here's the question that we've selected for you and this was coming. This is actually again coming from a non Psycho therapist.
Dr. Boland:Okay.
Dr. Horrell:Shout out to my hairdresser hairdresser, okay to our podcast. Wow, hello, I adore, okay, hopefully listening and we were talking when I was getting my haircut and he brought up this question and I thought I was like I really love this question and I wanted to hear you think about it, which is, how much is mental illness and mental health troubles related to genetics and brain chemistry and Ultimately, like, how much is that that needed to be part of for recovery? And I think this really is the question I got nature nature, Bioscigo.
Dr. Boland:Just talk about it and expound that all the time right.
Dr. Boland:So, so once again, so obviously not an expert, but sort of have talked to experts and you know, and they've been in the field long enough to have my own opinions, but you know. So think about it after laughter, because I do. I think you have one friend who was a Epidemiologic genetic, so he's like a geneticist person who's interested in kind of like how diseases Behave and who gets them and stuff like that, and whenever he's asked that he just rolls his eyes. I remember being on a, I think, a plane sitting next to me something, and he, when I asked him something like this as many years ago, and he just kind of said 50, 50, everything's 50, 50. I'm like, yeah, I don't think that's true. He goes, oh, who cares? That's close enough.
Dr. Horrell:I take the average of all of it.
Dr. Boland:I was yeah, there's nature, there's nurture. They're both important. Why are we talking about this? You know it's our. His attitude that, that being said, I think there's a bit more information out there, and he certainly would know that too, you know. I mean the way to think about is like what do we even mean when we're saying that? Right, because certainly, like you know, they asking of how much is biological, how much is not, is like a meaningless question. Right, because we're biological, everything's biological.
Dr. Horrell:Yeah, we wouldn't exist if we weren't exactly where we are biologic beings.
Dr. Boland:We don't have a non. If it's not biological, then what is it? We don't have some other thing. So you know, I mean. So I think I guess people are asking is like how much is hard-wired, like how much you know, if we think of genetics is like genes is being our blueprint of the camera, like the scaffold upon which we're sort of like Developed, we're kind of saying how much of that is is inevitable, I guess, is what people are asking because, in a way, you know, in the because, much like I said, everything's Biologic, in a way everything's genetic, because we, you know, we form from our genes, tell us how to form and how to develop and you know. So it's you know I don't want to get too much into that and you know, I mean I guess there's some information, it's it's kind of like the answer.
Dr. Boland:Of course it's hard to know and I'll say hopefully, if I think of it, I'll say more about why it's hard to know, but first I'll start with kind of what we do know. It's first of all, how do you know these things? How would you even design an experiment to answer this question, which is kind of hard to do right and it's hard to imagine, because how do you separate genes from environment? We live in the environment and we have genes. I mean the way that's. You know, the most classic way that people have been doing it for years is Through family and family studies, particularly twin stuff.
Dr. Boland:Twins adoption studies right exactly, and there's several of them out there, and the idea is that you know you want to get mono zygotic twins, so people who have the exact same, presumably the exact same gene blueprint, and Extra credit then, if they've been, if they were separated at birth, which is of course, hard to find, but they do exist.
Dr. Horrell:Wait real quick. Did you watch the documentary three perfect strangers? Yeah, yeah that one wait.
Dr. Boland:No, that's not the one that I tell us. More than that, you mean the three people who look exactly alike and from each other there's yeah well, three guys. There's three identical triplets who were separated for some reason.
Dr. Horrell:They were separated for science. Yeah that's what it comes out.
Dr. Boland:Yeah, I guess, I guess, I guess, yeah, it was like eerie. Yeah, and they had very different lives, yeah and stuff. But still strange things that they hadn't said Exactly and that became I can't say I didn't watch. The whole thing was kind of getting well I.
Dr. Horrell:The story is. The true story is about these kids who were basically genetic. They were triplets.
Dr. Boland:Yeah, it's a documentary, right?
Dr. Horrell:I think it's actually they were separated for the sake of science and studies, which is really pretty right, yeah, exactly.
Dr. Boland:Well, yeah, I'm not advocating that. So, yeah, so you generally you don't force these studies, so you're just hoping to find them without actually doing that. In a number of places, like in Virginia, there's the Virginia twin registry. I think some maybe I think it's either a sweet in or something I think has a registry that runs. There's several places where they Try their best to keep track of these things and do this stuff, and so that's where a lot of that it comes out.
Dr. Boland:Then you can imagine a, compare it like you know, different levels of similar genes, to answer the question. So you've got obviously the you know, monosagotic twins, so twins with the exact, you know, who came from the same egg that got separated and who have the exact same genes I have are the closest in genes because they're the same and then you have, like, for instance, dies agotic twins, so twins that I don't sure the exact same genes, but they're at least you know they're still pretty similar, they're half, they have half the same genes, and you know. And so you can imagine going down then to like other siblings and stuff and and people you know when, like one family member, like the mother, may have a mental illness. So you can imagine you, you try to track these things and sort of see, as you get further down the Downs for the family tree, how these things track and stuff. And that's where much of these studies come and like.
Dr. Boland:And of course they're hard to do because it's hard to get accurate data. Sometimes you know are the diagnoses correct that they have, especially if you start going back historically. So you know these things are right there. But, that being said, the best they can do from these things and the best data they can get, you know there's, you know what it seems like. Most, if not all things that we consider mental diseases have some genetic component, and you know, and some seem to have more than others. So let's take the ones that, like some of the, some of the disorders that seem to be like highly genetic worse, most, you know more than 50% seems to be genetic. You can probably guess what some of those are because they talk about.
Dr. Horrell:I think bipolar.
Dr. Boland:I'm a friend of you very good.
Dr. Horrell:That's the main one.
Dr. Boland:Yeah, what's in the other one be a childhood disorder, autism? Oh, yes, right, if you include that along the way, that's probably, in fact, that one's probably the most you know, genetic in a way, as far as being like having the blueprint for that and and that one, probably being like. So they talk about concordance, right. So, like you know, you know, when they talk about like how genetic it is, like if you're the identical twin of someone else, one of the odds that you'll have this disorder, if they have it.
Dr. Horrell:Yes.
Dr. Boland:And with you know autism is probably up around 80 90%. Yes, so like chances are, if your twin has it, you're going to get it.
Dr. Horrell:There's also like emerging research on the broad Autistic phenotype, yeah, which is that there are a lot of siblings who have a more gosh and I know there's a lot of language around this, I want to get right but have a different Kind of autism, yeah, where they might have a sibling who is Nonverbal and so the family definitely can see the autism more like present in that person's life, and then the sibling who maybe has more right I guess I should say less severe symptoms or the symptoms are harder to detect, they get missed until they're an adult, right? I? There's some.
Dr. Boland:Right, I guess in the problem of diagnosis. In fact you mean, even if you have the diagnosis, you may not have it. The same, yes, and that's true, as you can imagine, with schizophrenia, bipolar as well. So yeah, and with schizophrenia, you know, in bipolar they're, they're up there as well, probably in the 60 to 80 percent concordance rate. So better than half is your chances of getting it if you, if your twin has it as well.
Dr. Boland:Of course, what are they getting and why is this like so hard to do? Well, you can imagine, like once you go beyond the family stuff where you just kind of say they get it but you don't know why and what they're getting, and actually start to look at the genes, then it becomes even hard. I mean, you know, you can imagine for years what, and there's once again different ways to do the research. And In the past one of the ways they were doing is they look for a family that had a lot of one particular disease. So like there's certain like towns with families that had like, say, lots of schizophrenia or lots of bipolar disease, or Islands or something where it seems like a lot of the population have many things. Well, of course you can watch Freddie go out, study them and see what variations of the genes Do they have. That is like making them get it. So that's kind of one way to do it. You know, and you can imagine even then. You know, it's only been recently that we can sort of sequence the entire genome.
Dr. Horrell:Pretty good, yeah, pretty good Right.
Dr. Boland:And so you know, up until then you know you really couldn't do that. So you had to kind of strategize as your studies this height and even today, you know, it's kind of like, you know it's it's a lot of. Even if you can sync with the whole genome, it's a lot of data, that kind of manipulate to look for, often what are very small variations, so you know. So there's different ways to approach this research. You know one of the more common ways is well, you know, it's kind of analogous to, like, if I lose my car keys at night as I'm trying to go out to my car, where do I look for them? Well, I look under the lamppost first, where the light is, because that's I don't know if they're there, but that's the easiest place to look.
Dr. Boland:So a lot of genetic research is like that sort of go for like things you already know and sort of hope that you know this will be that something will bear fruit. So, for instance, like you know, a lot of like the research on let's take schizophrenia, for which there's been a lot of genetic research. A lot of it is around stuff where you're picking a few genes that you think might have something to do with schizophrenia. Like we know, schizophrenia seems to have something to do with dopamine, right, and it's you know why? Because a lot of the drugs that work for schizophrenia, you know, seem to do something to dopamine. So let's look at dopamine genes. So then they look at that and stuff and say, oh, is there anything, you know? Are there any particular dopamine genes that seem to work for these people? And you know, and seem to be more of like in one version, that dopamine gene is more common, this population, or is there some mutation that's more common or something like that? And the answer is you know, yeah, you know, yeah, but not always.
Dr. Horrell:This is where I do like. My mind is going 10,000 different places, because I think that, even though this is like, as you mentioned, it's a long had conversation.
Dr. Boland:Yeah.
Dr. Horrell:Genetics. Where, like, where does this arrive from? How much does mental illness come from genes and our biology? There's also, like so many, I think, philosophical and what's another good word for this? Like, like, like. They're just so much. Like, for example, one of the questions that I think comes up around this topic. Where does free will then play a role in regard to like?
Dr. Boland:All right, put that aside for a second.
Dr. Horrell:Okay, yeah, okay, but that's an other question I have for you at some point. I'm just going to say now is like, especially some of the psychiatric illnesses like depression or anxiety, would you consider them a singular disease?
Dr. Boland:Well you're getting to. Something else that they're discovering is that when the when you don't look under the lamppost and when you do do kind of wider studies, you often find that, like, some of the genes that seem to be involved in these disorders are not what you might have expected. They don't seem to do things that are obviously related to disorder, Like they don't affect like neurotransmitters or something else, and that's kind of curious. And so, for example, you know, like one of the more interesting studies of schizophrenia that came out like in the past decade I think it was around 2017 and 18, was like a large genome study that he looked at schizophrenia, and I'll give you the spoiler of it now. I mean, what they're finding in general is like, let's be clear, there's no schizophrenia gene. Now, hopefully that's obvious to everyone by now. There's no one gene that, like, if you have this particular version of this gene, you're going to get schizophrenia.
Dr. Boland:What they're finding is that there are many genes hundreds and hundreds that do little things, and each one makes your odds of getting schizophrenia slightly more, very slightly, and then if you have a lot of these, then you're much more likely to get schizophrenia than someone who doesn't have any of those right. So it's like a lots of, lots of different genes with small effects combined to give you the disorder. So to find those, I mean you have to kind of look through them. That wise, you can imagine these like whole genome studies where they're looking at lots and lots of different genes, you know, manipulating incredible amounts of data, trying to look for variations that kind of go with one disorder or not and like give me an example, like in the 2017 study, the genes that they found were genes that were very related to schizophrenia in their things compared to other genes. Still not, you know, still not like high, you know, high concordance, but more than other genes where one's involved with what's called the major histocompatibility complex. Well, you do kind of know what it is.
Dr. Horrell:I have no idea that was so generous.
Dr. Boland:Well, those are the genes like that are involved with things like inflammation and our immune system and stuff like that Exactly. You know the kind of like the fix it cells that we have in our body and stuff, so, so a lot of disease. The problem is, a lot of diseases are involved with that, which is kind of getting what you're saying and actually at first you know it was kind of scratch your head thing, like well, didn't see that coming. Whenever the study like why in the world were these genes of anything to do with? Schizophrenia, what actually kind of makes sense because of particular genes. Is this going too much? No, no, but the particular genes doing this. Okay, good, that knows enough. I'm going to keep going.
Dr. Boland:And it's the particular genes there are involved with kind of development and pruning and that you do know what it is right. I mean like we started out with all these connections like in our brain, smack in the microphone, all these connections in our brain, and then your brain slowly starts kind of like whittling down the connections for ones that you really need. I mean the way I see it is kind of like I don't know, like if you look at the back of my like my audio like multimedia system, like this cords going everywhere. It's like a total rat's nest and every now and then there's probably one in there.
Dr. Horrell:You just don't need it all.
Dr. Boland:There's more than one, and every now and then, like I make a user on the holidays, actually I kind of make a point to go back there and take a look and see is there anything I can like clean up here and stuff. Like you know, I think last year I was looking and you know mean 2023 and I looked and I like, well, is this cord going to? Well, it goes to my Nintendo Wii. Well, I haven't used an attendant like a decade, you know. So I don't need this court, so you take it out, and so your brain is the same thing for, you know, the first few decades of your life, that's what your brain's doing is, and it's these cells controlled by these genes that do that.
Dr. Boland:And there's more theories, not even just genetic ones, coming from other directions, saying that schizophrenia is a disorder of neurodevelopment, meaning that, like how our brain develops, like, are we, are we not? Are we sort of whittling down the right neurons, the right dendrites, the right connections along the way? Are we doing too much? Are we doing too little? Are we doing the wrong ones? That that may somehow relate to schizophrenia, and that's actually where a lot of the money is right now in schizophrenia research so you can see like how hard this complicated, and then like that. But when you look at those genes and say, well, are they involved with anything else besides schizophrenia? Yeah, they're involved with a lot of things, including autism, including bipolar disorder, so they share a lot of the same ones. So then it gets into like, okay, well then, why did this person become autistic and that? Well, because it's not just that gene, it's like other genes too. And this gets into just how complicated the whole thing is.
Dr. Horrell:Well, I think the piece where my mind goes is like some of the questions my patients bring at times, which is basically like is this all hopeless to me, Right?
Dr. Boland:This gets to your free will question. Do I have?
Dr. Horrell:any like am I?
Dr. Boland:just saying this. Is there anything I can do?
Dr. Horrell:Am I just a conglomerate? Of what's been passed down to me and do I have any say in how it changes?
Dr. Boland:Right and once again, the geneticists are the ones who are most comfortable with that question, in a way, because they feel like the problem with most of us is we think of like your genetics is one thing and like the environment is something else, and that they have nothing to do with each other. So like it's either your genes or your environment. And of course they know, and I think we kind of know, that no, there's a constant interaction between the two. I mean, the environment can affect your genes and your genes can affect your environment. And keep in mind we're talking environment in the widest sense. So like, starting from when you're in the womb, that's the environment. So like if your mother gets sick while you're in the womb, that's the environment in Pingeon to you and that may have something to do with certain mental illnesses and stuff If she uses drugs. You know, you can imagine all along the way and then, as you get out, the different stresses you encounter, well, they're not just stressing you in like a very direct way, they're also affecting your genes.
Dr. Horrell:Then you get immune system and your nerve.
Dr. Boland:Exactly. And then that gets into things like epigenetics I don't want to go there which has which, but that kind of gets into the sense of like how does it? You know, how does the environment affect your genes? It has effect back and stuff. So in a way you one could say that the question isn't very meaningful because you know everything affects everything in a way. So of course, if you can affect, that's the quote from this episode.
Dr. Boland:Everything Works for the second like you were seeing in the textbooks, like where you see like one diagram with different effects and there's, just, like you know, double arrows going everywhere, and then at that point I just kind of phase out and say like, well then it doesn't really matter, everything affects everything, and that's kind of how I see it here. So of course, if you can affect your environment, that can sort of like give you a better outcome. And does it affect you? By independent of your genes? Probably not you're probably improving your. That may explain partly, like, why some of those Autistic kids you're talking about some of them are very functional and why some of them are not. I don't know, but but it could, depending on, like you know and and even like you know, people brought up in the same environment, as you know, probably better than anyone, don't really have the same environment. Your birth order matters and there's all kinds of like. Every Many twins will say that they're not treated the same.
Dr. Horrell:Yeah, we all, you know, we always say like in the world of attachment, no one kid had the same parents exactly even though they did, they didn't right.
Dr. Boland:So even if you're in the same family, you don't really have the same environment and then there's temperament.
Dr. Horrell:And then there's your right. And one thing I've been thinking about too that makes us even more confusing, is that psychiatric illnesses Are even more confusing in my mind because they don't have as clear of, like, a tangible etiology. You know, like, if you have what's a good example of this, if you have appendicitis? Gosh, you don't know any of my appendicitis.
Dr. Boland:Yeah, why are we talking about that? Where you going.
Dr. Horrell:Well, I was trying to give like, some illness where, like you can point to, like, well, this was where it came from, or like we can see it, yeah see your appendix. You can see it's infected or inflamed or whatever.
Dr. Boland:Yeah, appendicitis, like we can, we can tell that people love that, or like a simple infection or something. Yeah like, yeah, but most diseases, actually in all of medicine, are not like that.
Dr. Horrell:Well, because I've been thinking about, and then I guess we'll wrap up this one, but yeah, I think that this is with depression in that, like we love to study depression in our field, we love to treat it as a illness. This is the major depressive disorder is a illness, it is an illness. Wow, I don't know if any of that what I'm just trying to say is making sense, but what I've been thinking about is, like depression is a a group of symptoms that tends to go together, but right any given person develops depression, and what their depression looks like is very that's.
Dr. Boland:That's not this question is about right, but exactly. But then you're getting to like how accurate, I like how valid are the diagnoses and that gets an no. It's not kind of don't, no, don't say that I don't, I don't agree, but we won't, we're not going to talk about that, um, but what I would say is that so there is hope in this thing and one of the some of things right and one of the things that you can do that like Helps your environment, affect your genes. Well, like a lot of things actually. So think about general health probably affects these things. If you know, if you are a generally healthy kid, if you ate well, your diet probably matters. Socio-economic, social, economic factors probably matter, both directly in terms of, like you know, the environment you grow up and like your exposure to things like educational opportunities, stuff like that, normal families and probably matter. The kind of stress you experienced as a kid Probably matters in through out. So there's all kinds of things that you can affect along the way.
Dr. Horrell:Now anybody could try to work on things like their sleep being hydrated yes, what they eat well being able to move their body. I was. I was telling patients I'm like the bedrock of what we're working on Is not going to work if you're not sleeping, staying hydrated, putting food, exercise and moving your body. Yeah, yeah, like those are some necessary factors to do any of this.
Dr. Boland:There's no mistake, I and we were going on that, like many of these things, when you look at studies, I mean, they always make it better Anyway. So that's kind of so. Yes, that's a hopeful note to end up. I love that, which is good, because I think the next question you can, you, you pose that we're going to do together is always like a. Bummer okay, fine.
Dr. Horrell:We got a question I think was a nice one, which was how do we deal with burnout and how do we like we, you and me how do we cope with and move through burnout, especially working with?
Dr. Boland:burnout. This is all like. That's just all like we're talking about, like in the medical world now.
Dr. Horrell:I've I've given several presentations on burnout and. I like to think of it as a very hopeful topic.
Dr. Boland:Okay, I think that good. I'm glad to hear that, because that's not often how it's posed. To me it's like ruining the medical profession. It and I don't mean to, I guess I don't mean to make a lot of it, but it is. But the problem is is that you know first one starts with what is burnout.
Dr. Horrell:What is, what do we mean?
Dr. Boland:by burnout. Do you have like? I mean, let's start by saying my bias is that, you know, no one really knows, because everyone uses the word a little bit differently and there's no like official.
Dr. Horrell:There's no official diagnosed burnout is the experience of I don't know I don't know.
Dr. Boland:Well, I mean start. Well, one of the things let's let's start simple. Why it's exhaustion. It is dread physical, okay physical, mental exhaustion.
Dr. Horrell:That's, that's. That's a nice business.
Dr. Boland:It tends to be people who feel no longer connected to their jobs or whatever you're burned out about, but it's usually jobs. That's what we're talking about, really. Things like that feel kind of like alienated from work and kind of no longer connected and stuff, and generally feel a sense of demoralization about it. Dread that what? Yeah, the dread stuff, the things that they do don't really matter.
Dr. Horrell:Yeah, and like, I think, the symptoms if there are symptoms of burnout, it is like people feeling like Really like not wanting to go to work, feeling like there's not getting a lot of meaning or satisfaction from work. Yeah especially for burnout around work.
Dr. Boland:Yeah.
Dr. Horrell:Um, having a harder time concentrating, having a harder time getting things done, right yeah?
Dr. Boland:And you know, and you know difference from things like depression, stuff, because it's like because of the target, this is something that's making you this, you know. So it's more like an adjustment disorder, in a sense and it is like depression, but the idea that you know, if you were to step away from the stresses that are burning you out, you probably would feel better.
Dr. Horrell:This way didn't like a in an analogy way to what you were just talking about. In that, I should say, as I entered this Question and saying was hopeful, I actually want to step back and say one of the things I thought about a lot with burnout is that I Do not like burnout conversations that focus on the individual. I think that that is unfair. I think a lot of burnout, and why and people end up experiencing burnout, comes from a systemic level, comes from the highest level of the systems in our country and how we have a particular kind of Work week and we have a particular kind of system Cough-cough capitalism. Yeah, I mean, I'm blaming the fact.
Dr. Horrell:I don't blame it, but like thinking about like we, the system that we live in in America, is Incredibly prone to burnout, and then each system in regard to like different organizations you work in, like they play a role, and so I think so much of the folks on burnout ends up being on Individuals and then ending up being like how do you individual keep yourself from burning out when it's like I'm in a system that's prone to burnout?
Dr. Horrell:Like that's not fair. So I should say, and the reason why that fell now, just for you were just talking about is like the Genetic component versus like what we can do component, and that that's where I don't want to compromise either, though, even though I think that there's a lot systemically. I think as individual people, we have some power. I can help us with this, so it's not hopeless. Yeah, I want to honor the fact that, like there is a system in place that, yeah, leads to burnout, and I I never want to seem like I'm, you know, quote-of-a-blaming or putting just the onus on the individual. You know, I think each individual has power.
Dr. Boland:I mean, what I would say is that, yes, though I know, though it's not, you know, those literatures, not just from the US, but there does seem to be, like you know, some people feel like, just you know, either an epidemic or a burnout now, or just it's something that people didn't talk about before and now we do, I don't know, unfortunately, I think, like, at least in medicine, most of the remedies so far and the discussion of remedies is around our spent working, yeah, which certainly is important I'm not saying it's not, but it can't be just that. I'll give you an example is that, like I was actually on, you know, the ACG, me like the group that oversees Residencies, and we're having a conference about burnout and stuff like that, and they're talking about, you know, changing. This is back when we were changing the Amount of hours that doctor, that resident doctors could work, was the purpose of the meeting and stuff, and that did happen. It was kind of to review some studies that were going on and things and to sort of make some decisions. As it happened, I was sitting next to a person about my age I'm old and I see next to an old, a neurosurgeon, and so I just kind of leaned over to him. I kind of said that kind of like okay, you're about my age, so like you were probably a resident about the same time I was.
Dr. Boland:And he's like, yeah, and he goes and like and what was your call? Like he goes. I was on call like all the time. Like all the time there were no duty hours, there was no protection. I was on the call like I never left the hospital. I live there for most of my residency. I'm like okay, so it's more than my call.
Dr. Boland:I remember my call was certainly busier than it is now for people, but here's sounds worse ago and did you hate it? And he goes. Oddly, he goes. It's one of the more exciting times in my life when I look back on he goes. Now I'm not saying I wasn't exhausted because I was tired all the time and I was grumpy sometimes too, stuff like that he goes. I'm not saying it was perfect and I was happy every minute he goes, but there was something very exhilarating about the whole thing and when we tried to kind of dial down to what was different than what people are talking about now, his sense was that what I did mattered, like I was really out there helping people and so, even though I was physically exhausted, I felt that it was worth it in a way that I think and I think the problem is is that so he wasn't demoralized, he was tired, but he would. And now I think the problem now is that somehow people don't feel that as much.
Dr. Horrell:This isn't really. This is kind of going along there saying but a little different to and I say this really gently but like were you married when you were going through residency?
Dr. Boland:Indeed, I was.
Dr. Horrell:I, I could imagine, I don't know, but do you imagine this man was married? He's going through residence.
Dr. Boland:I imagine he was.
Dr. Horrell:I think that there's also been a shift in regard to things like and I believe, I believe your wife was probably working, or she was yeah but I do think that there was like a difference in regard to Support systems, mm-hmm. I'm sure that's part of it at different times in regard to maybe particularly gender.
Dr. Boland:So your answer is to get married early. If you're gonna be doing that, get yourself a spouse?
Dr. Horrell:No, that's not. That is. The problem is, I think there's you have more people who are either lonely, not. There's a different level of support, like going, like if you're spending all hours of the day at the hospital but you have somebody who's able to do the grocery shopping and the cleaning and like Well, she was working full-time to who was doing the grocery shopping and cleaning?
Dr. Boland:I don't remember if you had to get.
Dr. Horrell:I like this. I like to think we shared it, but there is like I think there's just there's, there's changes that are here, would you say and and and. Yeah, I think a the meaning, but when you have more and more people.
Dr. Boland:I didn't see you going on. I didn't, I wasn't anticipating that direction. I think it's something to buy.
Dr. Horrell:Yeah, I think it'd be easier to be resident. I always I joke about this I'm like, oh, I was a wife. I was like wife's done great.
Dr. Boland:Yeah, everyone should get one.
Dr. Horrell:Yeah, absolutely. I was like I think my life would be here. Yeah, this is so shady to my husband. He does a lot, I love.
Dr. Boland:I'm sure he helps a lot.
Dr. Horrell:He does a lot and I love them very much and yeah, but it's like I think that there's something there's that.
Dr. Boland:But I think it's also something about, like, the nature of work, that like, if you find it like I mean I'm not saying that working people To exhaustion is a good idea and I have no doubt that if you work people too much they'll get burnt out. So I'm not minimizing that. But I think there's other factors as well. Like you know, to me, I think the most stressful part of work is when you have a lot of responsibility but little sense of control, which is, I think, how a lot of people feel, and that might have changed over time. So you're gonna get blamed for something that goes wrong, but there's not really a lot you could have done about it. That sort of thing.
Dr. Horrell:Here's the real question, bob Olin what do you do in your own life? I mean you do think about like the individual side of it, like what you do, how do you help protect yourself with your burnout?
Dr. Boland:Well, I I mean this isn't gonna be helpful, but I try to make my work meaningful. You know, you try to remember that there's parts of what we do that is very satisfying. I'm sure you have those experiences probably every day, where you help the patient.
Dr. Horrell:That's interesting. You go there because it's that makes so much sense. But that's actually when I was thinking about this question, not where I was gonna go. But that is like one of my things.
Dr. Horrell:I say like drink more or what I was gonna say like the typical kind of like self-care stuff and talk about like radical self-care. There's a great book out there I'm forgetting the author, but it's about radical self-care. That self-care is not just about, like you know, doing a face mask and whatever. Like self-care is about how do you really learn to like, prioritize and love yourself.
Dr. Boland:But I was gonna go that route from the be okay, so like self-care and do things in your go. What?
Dr. Horrell:I like when my parents worry about people in my life are like, yeah, it's such heavy work, like we're working with folks who are suicidal, traumatized, like we're sitting with that all the time and ultimately my sense is that I Like then they're worried about me. I'm like, yeah, but do you understand that? Like there's something so profoundly gratifying knowing that, yeah, at times I'm being with people and they're not so alone in it, that like that I'm able to be a non-judgmental, compassionate ally in their pain.
Dr. Horrell:Yeah like that is so meaningful and that's so beautiful. I don't know. Yeah, like that makes it worth it, even on the days it's exhausting.
Dr. Boland:Yeah, I mean, and I think we sometimes lose sight of those things. But and I'm not being polyanus, I'm not saying, like you know, just take more joy in your work and stuff. I like the other things matter as well. But I do worry sometimes that you know, you know that the corporatization of medicine sucks some of the fun from it.
Dr. Boland:Yeah and that I, you know, and and things, other things like, because there are things that obviously bring no satisfaction, like spending your time doing lots of medical records, right, exactly, so like. So I think that's where you know the more that we do meaningful things. I mean, obviously every job has a amount of meaningful stuff and a lot of stuff you don't like to do but you have to be as part of the job. The ratio of that, I think, matters a lot.
Dr. Horrell:Yeah, and ultimately, because I maybe on the flip side I think about too, I think there's a lot of movement, especially among, like, millennials and younger generations, to say, like your job doesn't have to be the thing and you're like that gives you meaning. Yeah, it can be the thing that you do to make money, and like I think that there's a way in which prioritizing a like, how do you Shut your laptop at five o'clock? How do you make sure that you, you are able to do your work in a way that you can use your time?
Dr. Boland:I guess it's true, though I I mean this, we're getting a far afield now, but it, um, I mean I feel like my generation and then your generation and the next generation are like the first, probably some of the first generations in history who actually had the luxury of choosing jobs that they wanted to do.
Dr. Horrell:Yeah, that's true.
Dr. Boland:Like my father didn't yeah. You know they, you kind of got a job Because you had to feed your family and whatever job you got, that's what, and the question of whether you found your work fulfilling was Kind of irrelevant. Yes you know. So I think I think at least a lot of people go into this now Kind of expecting that from work. Yeah they're choosing something they want to do, and then it it feels like a betrayal If it isn't fulfilling to them right, and so I would disagree with okay just in that like I think that there's plenty of people who do work that's like it's not necessarily like their biggest passion, but it's helping them.
Dr. Boland:I'm sure that's true. I have friends like that. I mean, I'm not saying it's everyone, but we're the first generation actually has the opportunity to do that. Like you know, you figure, like you know you want you to go way back and you just kind of did what your father did. Yes, I mean you know, I mean, like you know, the family, you know. But any rate, I I don't want to go on to on about that because I'm probably wrong, I don't have these things but all the same, you know, I think people's expect a certain amount of work. Even the millennials and stuff in the gen zers expect A certain amount of like enjoyment from the work and stuff like that, even though I do think they're better about saying that it's not all of their life. Yeah, you're, you're, you're climbing down, so you just don't agree.
Dr. Horrell:No, no, no, no. I totally agree. Honestly, I was thinking we're probably running up on time.
Dr. Boland:I'll. I know, like, what's the first thing? I mean, what's the first thing you say? When you came into I I made some comment about, like you know, you know having to do this now because I know you're very busy today, like you probably very big and yet you said something along the lines of like oh no, I love doing this because I'm like right, you're adding an hour to your day here. That is not part of your usual work. You've probably got a lot to go back and do.
Dr. Horrell:I'm late to my next Okay.
Dr. Boland:All right, so we'll wrap this up.
Dr. Horrell:I do love. I do love getting to think together and do this podcast together and like that is something that's brought me a lot of my satisfaction. I think this is a meta burnout thing, so for me, this is.
Dr. Boland:This is kind of burnout prevention.
Dr. Horrell:Wow.
Dr. Boland:All right, is that good to end up?
Dr. Horrell:Is that your burnout? Prevention too.
Dr. Boland:It is yeah, absolutely. That's why I'm here.
Dr. Horrell:Dear, dear listeners, just know that you listening supports us getting just thanks to mickey is feel better.
Dr. Boland:Please write and and let us know like other things you want to hear about.
Dr. Horrell:Honestly, though, that's a great place to end as we head into a new season. Please feel free to write us at podcast at meningeredu Topics ideas for speakers. We're really open because we love to do this right.
Dr. Boland:It helps us from getting burned down.
Dr. Horrell:Thanks for joining us for a next season and we're your hosts.
Dr. Boland:I'm bob bowland.
Dr. Horrell:I'm dr Kerry Harrell and thanks for diving in the mind dive podcast is presented by the meninger clinic. If you're curious about the professional experiences of mental health clinicians, make sure to subscribe wherever you listen.
Dr. Boland:For more episodes like this, visit wwwmeningerclinicorg to submit a topic for discussion.
Dr. Horrell:Send us an email at podcast at meningeredu.