Good morning everybody. Thank you for being here. It's 8.01. So on a Monday morning, you're all here. So thank you. I'm Eric Macias. I'm the moderator for this conversation today. So we're going to be together for the next 90 minutes. My job is to be the timekeeper. So I'm going to keep each one of these talks for 20 minutes, and then we're going to get together and have a conversation. Looking at you today, the first thought I had was about the Argentinian writer, Jorge Luis Borges, who before he became a bestseller selling books all over the world, millions of books, he published his first book and sold about hundreds, less than a hundred copies. And Borges one day said, but I knew every single one of those people. So for you to see you here today is to see the people that are committed to a new way of thinking about psychiatry and a new way of thinking about mental health is a way of looking at positives and to look at how we can not only take care of symptoms, but also have made people live better lives and accomplish and become what they can be. So without further ado, I'm going to have Dr. Dilip Jast be our first presenter today. Dr. Dilip Jast needs no introduction, but you know that he has been a professor at the University of California, San Diego for many years. And he was also past president of the APA. Dr. Jast has done research in schizophrenia, on geriatric psychiatry, and most recently in positive psychiatry. He is a mentor to many of us. He is an inspiration to even more people. And he is a force for good and for psychiatry worldwide. So it's a great pleasure to introduce Dr. Dilip Jast. Good morning and thank you, Eric, for a kind introduction. Actually, I'm just delighted and honored to be sharing this session with Samantha and Eric. So I'm going to talk on positive psychiatry, psychosocial determinants of health, focus on interventions, no relevant conflicts. I'm going to start with positive psychiatry and psychosocial determinants of mental health, and then I will discuss positive intervention and prevention strategies. I was president of the APA exactly 10 years ago and exactly in the same place, San Francisco, Moscone. And my main job was to make sure that the DSM-5 was published. And that was done. Again, it was highly successful. But many people say that DSM is the Bible of psychiatry. And it is not. Psychiatry is much more than DSM. Psychiatry is connected with mental health, not only with mental illnesses. And that's why I made positive psychiatry my presidential theme. And since then, we have had a number of great contributors, including today's speakers. So what is positive psychiatry? So we published an article on positive psychiatry. It is defined as the science and practice of psychiatry that focuses on study and promotion of mental health and well-being through enhancement of positive psychosocial factors like social relationships, wisdom, and resilience. And some of the best examples of these positive factors are resilience, optimism, and social engagement. Numerous studies have shown that in physically ill patients, resilience is associated with medically desirable behaviors. That is, taking better care of yourself, being treatment adherent, exercise adherent, following healthy lifestyle. And resilience is associated with greater longevity. Optimism. There's a meta-analysis of 83 studies of optimism. And they concluded that optimism was associated with better cardiovascular outcomes, physiological markers, including immune function, cancer outcomes, and mortality. So optimism was associated with longer lifespan. All of these differences were significant at P less than 0.005. Many of these studies control for things like past history, family history, use of statins, smoking, and so on. And they found that still optimism had a major impact. Social engagement. Even more literature. Meta-analysis of 148 studies, including more than 300,000 people across the world, different age groups, men, women, people with different diseases. They found 50% increased likelihood of survival among socially engaged people compared to non-socially engaged people. Wow. So there's strong evidence that this positive factor impact health and longevity. And as psychiatrists, we should be the experts in this. And we are. But unfortunately, we don't practice that. And that's why I want to focus on what we can do. The things I'm talking about apply to people with mental illnesses too. Schizophrenia used to be called a life sentence. That once you have schizophrenia, there is nothing you can do. Not true. We have found in our studies, and others also have, a sizable minority of patients with serious mental illnesses, including schizophrenia, have well-being scores in the normal range. And their well-being correlates with levels of resilience, optimism, and other positive traits. Not necessarily with their physical health or even psychopathology. Remission or recovery in people with schizophrenia is not an oxymoron. A bunch of people with schizophrenia, as they get older, they get better. One great example of this is Professor Eileen Sachs. She is a distinguished professor of law and psychiatry at the University of Southern California. In her teenages and early 20s, she developed schizophrenia. She was a Yale undergraduate. And after 20-some years of ECT, insulin, multiple hospitalizations, restraint, and so on, started getting better. And today, she is one of the most effective investigators, speakers, and advocates. Everybody should read her autobiography, The Center Cannot Hold My Journey Through Madness. There are a number of other people like her who have recovered from schizophrenia in later life. So why does that happen? So there are clearly psychological factors that are important, but also social factors. In the last 25 years, there has been growing focus on what are called social determinants of health. The World Health Organization defines these as conditions in the environments in which people are born, live, learn, work, worship, and age that have a major impact on health and health inequity. They account for 30-55% of health outcomes exceeding the contribution of medical factors like hypertension, diabetes, obesity, smoking. So this is actually strong empirical evidence showing that these factors impact health more than the usual risk factor that we talk about and we think about as physicians or clinicians. The best examples of social determinants of health include social connections, early life trauma, discrimination of different kinds, especially racism, housing instability or homelessness, food insecurity. These factors have far greater impact on health, including mental health and mental illnesses, than the traditional medical risk factors. This is a very nice meta-analysis done by Dr. Julian Holt-Lunstad and epidemiologists at Brigham Young University in Utah. So what this shows is the bars looking at all the reduced mortality. So the longer the bar, the better it is. The top three bars are the longest ones and these are all social relationships connected. The ones below that include things like smoking, hypertension, sedentary behavior, obesity, and so on. So social connections have greater impact on health and longevity than the traditional factors. So there are these psychological and social factors. Many of them are adverse, but also some of them are positive, like resilience, optimism, wisdom, and so on. So what can we do in our practice for ourselves, as well as, importantly, our patients? So we talk about positive psychiatry, the importance of these traits, but in clinical practice, how can we do that? So first of all, it is an addition to and not a substitute for current practice. I wish it were a substitute, but that's not possible, given the way our health care system works. But we can add that. And we usually ask our patients what is wrong with them. We don't ask them what is right with them. What do they like about themselves? What are their strengths? We ask about what caused the relapse. We don't ask them what prevented a relapse for three years. So we need to assess things like well-being, personal strengths, perceived stresses, and lifestyle, of course, by completing forms online or at clinic staff. The issue is that, of course, a physician doesn't have time. You know, we get 15 to 20 minutes to see a patient. What can you do? But it doesn't need to be done by us. We can have online evaluation that the people can complete at home, or the non-medical workers can help with that. Once we do these assessments regularly, every three months, online, and then the physician or the clinician sees the results, you will be able to identify the treatment targets and interventions. For example, if the social support is going down, you will focus on that. And use of technology, again, is going to be increasingly important. What are the examples of things that we can do? Online or staff-administered assessment measures of major psychosocial factors. These include some adverse ones and some positive ones. The positive ones, social network. Social network is so critical. As I said, social connections have greater impact on health and longevity than any other factor, period. For resilience, there is a 10-item Connor Davidson Resilience Scale. For wisdom, we developed San Diego Wisdom Scale, the shorter version has seven items. We also need to assess some adverse social determinants, such as UCLA Loneliness Scale, four-item version, childhood trauma questionnaire, because childhood adversity is so critical in mental illnesses, and experience of discrimination. And as I said, that has become, unfortunately, more common in recent years. So these are things we can do. Again, the physician need not do that. We can get them done by somebody else, and they become a part of the clinical assessment. Okay, once we do that, then what kind of intervention? There is considerable empirical research showing that there are interventions that can improve this. For example, for resilience, there is stress management and resilience training, or SMART. Mindfulness-based stress reduction. Master resilience training for the armed forces. These are all randomized controlled trials that show that these interventions are effective. Again, they're not effective in everybody, and they have their limitations, but they are there, and we should think about how we can do those things in order to help our patients. So one of the areas of my interest, actually, for the last several years has been wisdom, which is also a personality trait like resilience, and optimism. One question people ask is, oh, what can you do to wisdom? It's like intelligence, you're born with it, you can't change it. Not true. Wisdom is much more than intelligence, that's one thing. It includes empathy, compassion, self-reflection, emotional regulation, so on. Can we improve that? Absolutely, yes. We published a meta-analysis of randomized controlled trials that sought to enhance a specific component of wisdom. Three main components were looked at in the study. Empathy, compassion, altruism, that is pro-social behavior, emotional regulation, and spirituality. These were studies done in people with mental illnesses, physical illnesses, and those from the general population. Nearly half of the studies reported significant enhancement of that wisdom component, significant increase in well-being with moderate to large effect sizes. So once again, there is evidence-based, there are evidence-based interventions that we can use in practice that have been shown to be effective. Some examples of these interventions. This is a very nice study published from Spain talking about reducing cyber-bullying. As you all know, cyber-bullying has become a major issue, especially for younger people today. So this is a study that included 176 teenagers in Spain that developed what is called Cyber Program 2.0 to prevent bullying and cyber-bullying. There were 19 group sessions, structured, which lasted for about an hour. And these were often done online, on Zoom, so virtual. They included role-playing, brainstorming, case study, and guided discussions. There's a control group, and they found that Cyber Program 2.0 increased empathy and reduced the amount of bullying and cyber-bullying compared to the control condition. You know, so this, we all know cyber-bullying is a major problem. What do we do with that? We can do something. Again, you know, no single intervention is going to solve all the problems, but we need to think along those lines, right? We recently published a paper on group intervention to raise resilience and wisdom and reduce loneliness in older people. So this was a study done in a senior housing community. We developed a manualized intervention, 90 minutes, once a week for four weeks. And the intervention was not given by MDs or PhDs or even master's level worker. It was given by the trained staff in that community. Of course, we trained the staff how to give the intervention. It included savoring engagement in value-based activities, gratitude diary, and homework. The outcome was a significant increase in scores on resilience, wisdom, and well-being and reduction in loneliness. Again, this was a randomized controlled trial using a lay therapist who was trained. Another intervention that we just published, this was a remote intervention, entirely on Zoom. Again, manualized one-hour session of CBT-based intervention, again, given by trained non-doctoral therapists. This was done in older people, and we found a very high adherence and satisfaction. And these were people who were selected because they had higher levels of perceived stress and loneliness. Again, both of these problems are common in older people. And we found a small to medium effect size reduction in stress and loneliness, an increase in resilience, happiness, and components of wisdom. Trauma. You know, we all know that early life trauma is really terrible. It increases the risk of schizophrenia, substance abuse, depression, bipolar, you name it. And this early life trauma, including prenatal, natal, postnatal, is serious because it affects expression of genes and that lasts for the whole rest of the life and may even be transmitted to the next generation. That's what makes it so serious. But we can do something about it, and that is psychotherapy. There's a study on successful treatment of PTSD with trauma-focused psychotherapy in soldiers. They found that a number of these soldiers did well. Importantly, there were changes in their epigenetics, significant changes in the DNA methylation at 12 differentially methylated regions in the genes. And these epigenetic changes produced by psychotherapy can also be permanent and may potentially be transferred to the next generation. Again, this is emerging research. You know, nothing is proven so far. But what it shows is that we give up on early life trauma, saying there's nothing we can do. Not true. We can, with psychotherapy, we can potentially reverse the changes that early life trauma caused. So what do we do when we see a patient with schizophrenia? Typically today we prescribe antipsychotic supportive therapy. Obviously, we need those. But in addition, we should also use cognitive behavior therapy, social skills training, physical activity, socialization, healthy diet, job or volunteering, positive attitude, and something called social prescribing, which is becoming common in UK and Europe, where you refer patients to the community agencies that can take care of their problem. So the last few couple of minutes, I want to spend on looking at this positive psychiatry at the societal level. It's not this individual, but what can we do at the community level? So wisdom. We have several studies that show that wisdom and loneliness go in opposite direction. Higher the level of wisdom, especially empathy, compassion, lower the level of loneliness. It is possible that it's also true for discrimination and wisdom going in opposite direction. So what should we do? Loneliness has become an epidemic, pandemic, and what we can do is by improving wisdom, wisdom in education, wisdom in healthcare. How can we increase? In education today, the entire focus in the grades you have, right, the hard skills, but we don't focus on soft skills of wisdom like compassion, self-reflection, acceptance of diverse perspectives. So we need to assess, teach, and reward people who do those things. It's like not just awarding the champion in any sports, but also awarding sportsmanship. Wisdom in healthcare. Again, assessing, promoting, and reimbursing team healthcare based on positive psychiatry. One very good example of this is Compassionate Communities Movement started in New Zealand, now in Europe, and hopefully will come to US. So what they have shown is that you bring together the government, businesses, academics, and so on, and develop a plan for helping the most vulnerable people in your own community. And what you do is by you find ways in which we can support and empower clients to set personal health code and make the community connection. So these are, again, community-level interventions that we can think about that can improve positive psychiatry at that level. And thank you very much for your attention, and Dr. Mesa has to take over. Thank you. It's my great pleasure now. Thank you, Dilip. It was wonderful. And we're going to, we are going, we are on a live broadcast, so you should know that, number one. There may be questions from that online audience that we're going to address at the question and answer stage. We're also going to address your questions when we get to that point. Now, it is my great pleasure to introduce our second speaker of today, Dr. Samantha Broadman. Dr. Broadman is a clinical instructor of psychiatry, and she is actually the founder of a website called positiveprescription.com. And she has a newsletter called The Daily Dose that I would recommend to you on Substack. She's also written a couple of books. The most recent one, Everyday Resilience. I think it's the most recent one. Everyday Vitality. Everyday Vitality is the new one, okay. Her work has appeared in, and this is how when you see somebody that is influential and connected and articulated with a good message. She has written in Vogue, Marie Claire, Harper Bazaar, and Refinery29. She has been featured in Psychology Today and the Huffington Post. And I'm very impressed, and I'm very glad to call her a friend. So, welcome. Help me welcome Dr. Samantha Brodman. Thank you. It is such an honor to be here and to be invited to talk about truly my favorite topic. And I just want to thank Dr. Geste and Dr. Macias who are just extraordinary tailwinds in promoting positive psychiatry, but just mental health in general, in reaching populations that don't necessarily have access to the sort of experts who are out there. And just to applaud both of you for bringing this to all of us and to so many who don't necessarily have access. So, thank you. And this is sort of an extraordinary group. All of you are tailwinds, and I look forward to having a bigger discussion with you about the impact positive psychiatry can have. So, here's a question for you. What does wellness mean to you? This question was actually posed to over 6,000 people living with mental illness in 2018. And what do you think they cared about most? Well, they cared a lot about better treatment. They cared a lot about better understanding of their illness, better neuroscience, genetics, why do they have what they have. But what did they care about most? A sense of purpose, better connection. Put simply, they cared about having better days. And as one patient said, to me, wellness means stability, well enough to hold a job, well enough to enjoy activities, well enough to feel joy and hope. So, patients don't only want to feel less bad, they also want to feel good. They want to find wellness within their illness, as Dr. Jeste raised earlier. But what does traditional treatment focus on? Well, diagnosis of illness, alleviating suffering, and symptom management. Here's our definition, yes, of what psychiatry is. The branch of medicine that focuses on the diagnosis, treatment, and prevention of mental, behavioral, and emotional disorders. But in 2012, as president of the APA, Dr. Dilip Jeste, you just heard about, sought to expand this definition. And in his inaugural address that you just heard about, you called for more. We should not be satisfied merely with treating patients with mental illness, but with improving their overall well-being. So, this was the dawn of positive psychiatry, really 11 years ago today. And here we are 11 years later, with so many articles published, and books out there that have extraordinary resources for positive psychiatry. And here's just one way to think about positive psychiatry. Have you ever watched expert backcountry skiers, when they put these, they're on YouTube, they'll put these GoPro videos of themselves going through the trees, and it is just, your stomach's in your throat as you watch this, and they're going through the trees, and all you see is the trees. And here is what I mean. And it's just terrifying. But when you ask these backcountry skiers, how do you do this? Oh my gosh, this is terrifying. They say, oh, the trees. Well, yes, the trees. But we look for the patches of snow. That's what they're looking for. Not just the trees. And I think that's what positive psychiatry is really doing as well. So, because treatment that exclusively focuses on alleviating symptoms and suffering, it's just avoiding the trees. It's not aggressing what patients care about most in their quality of life. So when the focus is primarily deficit-based, clinicians and patients miss out on opportunities for exploring possibility and potential and fulfillment, because even when symptoms are under control or a patient is at their baseline, they may not be thriving. Or as Martin Seligman, who's the founder of Positive Psychology, once said, as a therapist, once in a while, I'd help a patient get rid of all of his anger and anxiety and sadness, and I thought I would then get a happy patient, but I never did. I got an empty patient. And that is because the skills of flourishing, of having positive emotion, meaning, good work and positive relationships are something over and above the skills of minimizing suffering. So pathogenesis, which is the study of treatment and treatment of disease, is not the same as salutogenesis, which is the creation of health. Positive psychiatry is the science and practice of psychiatry that seeks to foster salutogenesis, while also attending to pathogenesis. It's taking care of the trees, but also looking for those patches of snow. And it is based on the principle that there is no health without mental health and that mental health can improve through preventative and therapeutic strategies. So my goal today is really to provide you with practical ways to integrate the tools of positive psychiatry into your everyday practice and maybe apply them even to your own life and to hopefully enhance your patient's wellbeing and also yours. So what is a positive psychiatry intervention? They're defined as treatment methods or intentional activities that aim to cultivate positive feelings, behaviours or cognitions and they're evidence-based, intentional exercises designed to increase wellbeing and enhance flourishing. And although they were originally studied as activities for non-clinical populations, they are increasingly being used for their therapeutic role in treating psychopathology. And by adding these interventions to our toolbox, we can expand the range of treatment options and better engage patients in the treatment process and bolster positive mental health. So here are five interventions I'm going to focus on today. This was from an article actually that we published recently with Dr. Macias. I can send you all the link to it. So teaching patients to adopt a positive orientation, to harness their strengths, to mobilise their values, to cultivate social connections and optimise healthy habits can provide not only a counterweight to the traditional emphasis on illness, but we also have the potential to enhance the range and richness of their experience. So adopting a positive orientation, what does that look like? As Dr. Jessie said, when we meet a patient for the first time, what do we say? What is that icebreaker? What's wrong? We focus on the chief complaint and conversations tend to revolve around problems, failures, negative experiences. What's the problem, right? There's a great deal of evidence that there is therapeutic benefit to emphasising and exploring their positive emotions, experiences and aspirations, because it creates with psychologist Barbara Fredrickson calls an upward spiral. Not only do positive emotions balance negative ones, they create enduring positive feelings and promote what we think of as an approach mindset. It's when we put ourselves into discover mode, not defence mode. Just a 14 day study, this was during COVID, conducted during the pandemic, found that higher levels of positive emotion were associated with greater resilience and lower levels of perceived stress and better subjective health. So it's not just about the undoing of negative emotions, positive emotions have an independent benefit as well. Here, you can consider one way for you to think about doing this is to add to your toolbox. You could ask a question to your patients as they come in. What was your sense of wellbeing this week? What is your hope for today's session? What is your hope for the coming week? This reorients a session toward an individual's potential and promotes the exploration of what's possible, what they could look forward to. To promote a positive orientation, you could consider integrating the three good things exercise into your repertoire to activate and enhance positive emotional states, such as gratitude and joy. In this exercise in which patients are asked just to notice three good things that happened, it promotes positive reflection. And in addition to coping with life's negative events, deliberately enhancing the impact of these good things is a positive emotion amplifier. As you can see from this slide, not only did those who participated in this exercise have less stress and fewer mental complaints, they also had fewer physical complaints. It was interesting. So the next intervention is harnessing their strengths. A growing body of evidence suggests that in addition to focusing on a patient's chief complaint, identifying and cultivating their strengths can mitigate stress and enhance wellbeing. Signature strengths are positive personality qualities that reflect our core identity. And the VIA Strength Survey is one that you can use. So to incorporate this into your clinical practice, ask patients to complete a strength survey using the VIA scale. You can find it at viacharacter.org. It takes 20 minutes. It's actually kind of fun. So after you identify your signature strengths, you ask your patients then, explore them in everyday life. Can you try to use this in a new way? So in addition to becoming aware of and using their strengths, encourage them to strength spot in others. Do they see maybe their colleague, their coworker, their family friend, or someone else around them using a strength today? It's something you could explore. This is a wonderful study looking at sort of treatment as usual. Patients with depression were divided into two groups. Half received the classic deficit-based treatment that was tailored to work on their weaknesses and symptoms. And the other half participated in a strengths-based treatment. They targeted their capabilities and their skills, things that they were already good at. And the researchers found that deliberately capitalizing on their strengths outperformed treatment that focused on their weaknesses. So this challenges the assumption that we need to fix problems before focusing on anything else. Oh, we need to mitigate, you know, deal with these symptoms before we can promote maybe what's meaningful to them. So instead of exclusively troubleshooting with my patients, I look for bright spots. I inquire about what they are like at their best. We explore strengths, and I ask them to use them in new ways. And I ask them to consider how they might creatively use that strength to help them navigate their way through a challenging situation. These strengths-based interventions, treatment becomes more fun. It's more personally meaningful. It resonates with them. Plus, integrating strengths into this typically negatively skewed narrative underscores to patients that therapy isn't only about untwisting distorted thinking, but also about harnessing their talents and capabilities. And strengths expressed through pragmatic actions can boost coping skills and enhance wellbeing. So next, mobilizing their values. Value affirmations exercises have been shown to generate lasting benefits in creating positive feelings and behaviors. So what does that mean for you as a clinician? That would be encouraging patients to think about what they genuinely value, and this redirects their gaze towards possibility and diverts self-focus and rumination, which is an on-ramp to depression. Asking a patient to identify two or three values and write about why they're important to them is one exercise. By reflecting on their values in writing, they affirm their identity and self-worth, and they create a virtuous cycle of confidence, effort, and achievement. Studies show that people who put their values front and center in their everyday lives are actually more attuned to the needs of others as well as their own needs, and they make better connections. Studies found that students who were asked to write about their values were more empathetic and had more gratitude. So including their values in the treatment plan can increase problem solving and boost motivation and build better stress management skills. Another option is a life reviews exercise or intervention that facilitates exploration of a patient's values. This involves asking patients to recount the story of their lives and the experiences that were most meaningful to them, and this allows us as clinicians to gain a deeper understanding of their values. I think by creating more overlap between what they care about in their everyday actions and their behaviors, this bolsters resilience, it buffers against stress, and it can restore what we think of as a healthier self-concept. Now, this one, cultivating social connections. This is the fourth intervention I wanna talk about. Dr. Jeste mentioned, and this is so important, how can we prescribe social connection? It's recognized as a core psychological need and really essential for well-being. The opposite of connection, which is isolation, has negative effects on overall health, including inflammatory markers, depression, and mortality. I'm sure you've all seen that 2015 study showing that loneliness was associated with increased mortality, and similar to the increase is seen with smoking almost a pack of cigarettes a day. So as with any vital sign, asking about and exploring a patient's number of social contacts, the quality and the quantity of their social visits a week, it's an important indicator of health. Just as we need vitamin C each day, we also need a dose of the human moment, positive contact with other people. Asking about it and giving patients tools to cultivate social connection and deepen their relationships can enhance therapeutic outcomes. Studies show that social connection is the strongest protective factor for depression. And we think about what characterizes a healthy person or even a flourishing society, as Dr. Jeste mentioned, one factor that contributes to both is pro-social behavior. Asking patients to perform acts of kindness is one example of a social prescription. Feeding a stranger's parking meter, picking up litter, helping a friend with a chore, volunteering are all potential ways for patients to engage in kind deeds. And after each act, ask the patient to write down what they did and how it made them feel. A study from 2015 had found that when we add value, that it really is this extraordinary antidote for stress. We often turn to others for social support when we're feeling stressed, but these new results suggest that proactively doing things for others may be another effective strategy for coping with everyday worries and strains. Similarly, on days that people engaged in higher than usual levels of pro-social behavior, it buffered negative effects of daily stress on positive affect, negative affect, and overall ratings of mental health. There's also a well-documented positive feedback loop between pro-social behavior and positive emotions. Helping others tend to put people in a good mood, which in turn made them more likely to help other people. And it also bolstered positive social behavior and positive social connection. This was a study that was done during the pandemic and looking at graduate students who were arguably under a ton of stress. And some of them were asked to help high school students who were also super stressed out. And here's what they found, that those who were actually helping those other students, they reported better mental health, better resilience, and lower stress levels. A 2023 study published in the Journal of Positive Psychology found that doing good deeds for others boosted positive emotion and improved symptoms of anxiety and depression. And that interestingly, it was even more effective than CBT. Members of the kindness group were instructed to perform three acts of kindness a day for two days out of the week. And acts of kindness were defined as big or small and that benefited others or made others happy. And everyone in the study did feel better, including the CBT group. But it's interesting to note that the acts of kindness group showed an advantage. So prescribing positive communication into pro-social acts is another way to enhance a patient's social connections. So a brand new study, this is just hot off the presses. We said this is novel psychiatry interventions. This shows how quality conversations boost everyday wellbeing. And the researchers found that just one good conversation with someone during the day made people happier and less stressed at the day's end. And these are the different types of conversations that people were asked to have. And regardless of the type a participant was assigned to have with a friend, they all made a difference. The very act of intentionally reaching out to someone in one of these ways enhanced connection and reduced stress. And just one conversation was enough. Of course, more was better, but the more people listened, the more that they showed care, the more that they took time to value another's opinion, the better they felt at the end of each day. So not surprisingly, the study found that high quality face-to-face interactions and communication was more closely associated with wellbeing than electronic or social media ones. But it's powerful. Another intervention hot off the presses, this was about forgiveness. The study found that there was a statistically meaningful reduction in depression and anxiety in those who engaged in a forgiveness exercise. Dialing down resentment, anger, and suppression of negative thoughts likely contributed to this. And also the report of people feeling more connected emotionally and more positive emotion. This is just a two-hour self-directed workbook that people engaged in asking them to go through these five steps, the reach steps. So bottom line here, counseling a patient on increasing social connections, prescribing connections, and inquiring about the quality and the quantity of their social interactions can help them not only add years to their life, but also add health and wellbeing to those years. So the last type of intervention I wanna talk about is optimizing healthy habits. Dr. Jeste has already spoken extensively about it, but mounting research shows that exercise, sleep, and nutrition are essential ingredients of mental health. There's evidence that therapeutic lifestyle changes not only reduce depression, but also boost positive feelings. And numerous studies have demonstrated the benefits of sleep, diet, exercise, and interventions for reducing depressive symptoms in psych patients. This was in the Lancet a couple of years ago. While the determinants of mental health are complex, the emerging and compelling, there's emerging and compelling evidence for nutrition as a key factor in the high prevalence and incidence of mental disorders suggests that nutrition is as important to psychiatry as it is to cardiology, endocrinology, and gastroenterology. So we know from research that healthy diets increase happiness and vitality. So ask about what your patients are eating and drinking. Is it possible to prescribe the Mediterranean diet? Is it possible to engage them in learning how to cook or talking about simple meals that they could prepare and maybe doing it with somebody else? These are expensive. We know that and we know that pilot programs where you've just made fresh fruits and vegetables available to people, that they report better, greater vitality even within as short as two weeks. Similarly, when you give somebody like basically McDonald's, I shouldn't say that out loud, but a high fat sugar packed breakfast just for three days, their mood shifts, they can't focus, that they have a harder time paying attention and so much so that even their partner notices. So we can just see the impact of what we put in our bodies and the effect that it has on our mental wellbeing. Similarly, a study published in the British Journal of Medicine reviewed more than a thousand trials examining the effects of physical activity on depression, anxiety, and distress. And it showed that exercise was as effective in treating mental health issues and can be even more effective in medication or counseling. Along these lines, this is a similar study, found that those who exercised had reported fewer mental health days and felt much better. Of note, the boost in mental health were in those who engaged in sort of pro-social sports where there were teams involved, where they were doing it with somebody else. You get this kind of win-win when you're physically moving, but you're also doing it with another human being. Other lifestyle factors like decreased social media, pet ownership, spending time in nature have been shown to contribute to wellbeing and boost positive emotions. Doctors in England are now prescribing walks in natures and in parks. So despite the substantial evidence that lifestyle factors can improve health outcomes, few clinicians actually ask about or promote these positive habits. And surveys show that patients wish doctors would address this more. Here are just some simple ways to think about adding lifestyle interventions to your clinical practice. Just ask of simple ways to talk about this. What is a simple way to just start your day better and make it time limited? We all know about SMART goals that could maybe add, you know, just ways to kind of bring the conversation on. It's always better when it's generated by your patients rather than by us. But here's maybe ways to get the conversation going. Inquiring about a patient's typical day, such as how they spend their free time, what they eat, when they go to bed, how much time they spend outdoors, opens conversations about general wellbeing and shows the patients that therapy is about the whole person and more than symptom management. Helping patients have better days can empower them to lead more satisfied lives. So in conclusion, by exploring and emphasizing potential and possibility, we can create a better balance between pathogenesis, the study and understanding of disease, and salutogenesis, the study and the creation of health. Moreover, we can help patients find wellness within illness. We as clinicians are so well-positioned to manage symptoms and bolster positive states. Rather than an either-or approach to well-being, we can strive for a both-and approach, and that is really the aim of positive psychiatry, to be thinking about those trees, but also making sure we see those patches of snow. And by adding these interventions to our toolbox, we expand the range of treatment options, better engage patients in the treatment process, and bolster mental health. So don't just avoid those trees. Please look for those patches of snow. Here's one way to think about it. Watch this guy problem-solve. That's positive psychiatry. Thank you so much. So I'm going to try my best to keep you informed and entertained in the next 20 minutes or so and I am going to time myself. I'm Eric Messias. I'm a psychiatrist like I think most of you. I see patients. I'm also an academic psychiatrist. I have worked with residents all my life and I am now the chair of psychiatry at St. Louis University. It's been my pleasure and honor to do that. And I'm also the chair of this seminar today so I guess I like being a chair at some point. I am glad to be here because this topic of meaningful work started for me in a very negative way. Like many of us I was interested in disease as a psychiatrist and like many of us I actually was touched by a colleague committing suicide which is how I decided to study burnout. So again I was looking at the negative stuff and then I decided to think about work. If I'm a positive psychiatrist I should be able to think about work not only as causing burnout but also as being a positive thing in your lives. And it's actually more complicated than that. I have very few messages for you today in this talk. The number one is that we are very ambivalent about work. We are divided as a culture and as a civilization on how we think about work and I'm going to give you examples of that. Let me start by showing you a simple fact. The red bars is how much time you're going to spend in doing paid work in your life. It's the largest bar except for sleep. So this is average of hours of your waking life across the world and in every single country but one. Most of your wake life is going to be spent at work. Aren't you guys curious about who is the one exception? Any Italians here in the room? Italy is the only country that they have something to do something else more than work and it's actually housekeeping and shopping. So I always wish I had an Italian to comment on that but we in basically the whole world most people are going to spend most of their lives working. So that's most of your days. So I guess one first point is work is important for us as psychiatrists. And then we look at the state of the workforce and now let's take a look at the state of public health workforce and then you look and they say well half of us are suffering from symptoms of depression, anxiety, PTSD or suicidal ideation. So we have work has an effect on us. It can be a negative effect but my point here today can also be a positive effect. So let me now I'm going to introduce to you the following idea. This is what I learned as I started to read about work. There has been this raging debate about work for the last 50 or 60 years and I see us out of it as mental health people. But I'll tell you philosophers, economists, sociologists, anthropologists they talk about work all the time. There are tons of studies about work. There is a whole industry working around work. So I'm going to summarize that whole industry to you in one slide. There are two major facts. So you can summarize 50 years of research about work with two facts. One, most people's sense of dignity and self-worth is caught up in working for a living. It's built up by your work. Number two, most people hate their jobs. So that's what I'm trying to tell you. We have this we have this love-hate relationship with work that I'm going to point to you is actually not new. The next is a history of work. So historians have looked at work as well and the way they summarize you can summarize the history of work in six words is from jobs to careers to callings. there are still jobs to be done. It may not be there way for long, actually. So there is a whole industry talking about the end of work. But I'm going to point that to you in a few slides. Now is the audience participation moment. Because I have looked at this in many different ways, I basically have six different lectures to give you. And I'm gonna let you pick one. And so I'm gonna start with this one. I'm gonna tell you the quick message. The first one is about depression, the prevalence of depression by occupation in the United States. The second one is a summary about positive psychiatry from a book called The Happiness Advantage. The third one is just quotes about work. Quotes about work. And then the fourth one is an overview about working hours. How much have we worked over time? Which may surprise you. This fifth one is about burnout. And then the final one is about measuring meaning at work, in work. Pick one, if we start. Measure meaning at work. Measure meaning, okay. Let's see if this is gonna work. Of course it's not gonna work. Supposed to have a zoom there. I will get to you, I will get to you. Thank you for picking that. It's always a toss between this and another one that I'll tell you if you pick. Let me point, okay. Measure meaning at work. Okay, so what I'm gonna try, so back to my summary. What you need to think about, one way to think about work is that work can be meaningless and can be meaningful. We need to find meaningful work. Because for actually a double, there is a double reason for that. Meaningless work causes anxiety, depression, maybe suicide. In meaningful work, that's the opposite of that, okay? So as a negative, typical psychiatrist, I can look and I can, my first lecture was about the prevalence of depression by work category. However, however, the flip side of that is meaningful work does the opposite of that. So if meaningful work is so good, and that is one area, thank you for picking that, one area that I have actually published, and I published, I think I may have my, my paper was on the relationship between meaningful work and burnout risk, and we basically found that those people that feel their work as meaningless have an incredible level of burnout, and people that find their work as meaningful have very low risk of burnout. So meaning in work is protective to you. But then you may ask, how do you know that? How do you measure meaning, and what does, what is meaning at work? I'll tell you. There is a philosopher called Andrea Veltman, and she developed, she has a whole book on meaningful work, and she has four ways to categorize meaningful work. First of all, meaningful work develops or exercise the worker's human capabilities, especially in so far as the expression of needs, meets with recognition and esteem. So it helps you develop who you are, develop your strengths, like Dr. Broadman talked about, the strengths that we all have. Good work makes you work on your strengths. Number two, support virtues, including self-report, honor, dignity, and pride. We have to talk about these values in work, of self-respect and dignity and pride in what we do. Number three, provide a purpose, and especially producing something of enduring value. Do something that you find valuable. Do something that you believe is a good thing. And the fourth category for meaningful work is integrating elements of a worker's life, such as by building or reflecting personal relationships, or connecting a worker to an environment or relational context in which she deeply identifies. So find that place that you feel you belong, and be there, and be present, and develop your strengths. That's meaningful work, okay? So meaningful work develops your strengths, gives you self-respect and dignity, provides you believe you're doing something good, okay? And makes you feel that you belong where you are working. That's meaningful work. There is a way to measure it. Of course, psychologists will find ways to measure anything. There is an inventory. I want you to take that with you. It's called the Work and Meaning Inventory that has all these different correlations with job satisfaction, life satisfaction, negative correlation with depression, and hostility, okay? So what is it like? You have to go through this scale of 10 items, and you have people fill them up. That's the scale we use in our paper. We measure meaning, like this, using this scale, and we measure burnout at the same time. And the correlation is a very strong negative correlation. You can find this on the web. There is another model to look at meaningful work. It's called SCARF. It's easy to remember. It's called Status, Certainty, Autonomy, Relateness, and Fairness. Now, here is something that is a little bit tricky, but some of these factors, they are negative correlated with each other. A work with a lot of certainty has very little autonomy. So you need to find, if you are the type of person that values more certainty, a paycheck at the end of the month, you can go get a federal job in the VA. You know you're gonna get paid a certain amount of money every month. Or, if you like autonomy, you can go to private practice and you say, I'm going to work as much as I can this month because I want to make more money or less money. So these values are actually balancing each other. And then you can measure that too. There is a way to measure that using this scale. How much do you feel threatened, or how much do you feel reward by status, certainty, autonomy, relateness, and fairness, sense of fairness. And I think, so I'll tell you this. As I work with younger generations, I feel that different generations value things differently. So this younger cohort that we see now seems to value more fairness and relateness than some of our old folks that tend to buy more certainty in the work. So, I want to give you a chance to pick another topic before I go to my summary. Oh, the happiness one! Let me tell you this, what the happiness one is here to do is just to remind you that all these positive interventions that Samantha talked about, that Sean talks about in his book, they all can be done at work. They can all be implemented in the workplace. So what I think we need to do is to help people find ways to do these things in their workplace. Because my first point was, most of your waking life is going to be spent at work. So you can do meditation, mindfulness, mindset, you can do gratitude and optimism at work, you can look at post-traumatic growth, even if there are difficult times. And I will spend now a minute saying that one of the most common misconceptions about positive psychiatry is that we have rose-tainted glasses and we see everything as positive. No, no, no, no. Life has a lot of negative stuff, has a lot of pain and suffering and loss. We psychiatrists know this better than most people. We lose people to suicide. So there are moments that life will be tough. The point that Samantha makes is resilience is what happens when you do that, when you go through the hard days and the hard times. So let's do that. That was the summary of the book. It is a good book if you want a summary of positive psychology by 2018 or so. So I will finish. I'm going to give you some quotes about work and then I'm going to go to my summary. Here's why I say we are so ambivalent about work, loving and hating work through time. I'm going to start at the very beginning. So the literal beginning for people of the book, for Christians, is the Genesis. The very beginning, God cursed us with work. So one way that our civilization looks at work is a curse from God because we misbehaved. So curse is the ground because of you. In toil you shall eat of it all the days of your life. So we were cursed by God at the very beginning of this. In the sweat of your face you shall eat bread until you return to the ground of which you were taken. So at the very core of the Christian tradition, work is a curse. But then something happens. Paul writes a letter. So now as we're going from the Old Testament to the New Testament, Paul writes a letter to the Thessalonians and he says, I work because I don't want to be a burden to you. So Paul is proud of his work saying, and then he says, if a man will not work he shall not eat. Settle down and earn the bread they eat. So for, this is now the Christian version of things, work here is something that you need to do so you don't burden others. That you are sharing the burden of being part of this community or this society. So you see how work is part of how the way we see ourselves for a long time. And then you have Popes. There are two papal documents specific about work, okay. In one of them he says, Pope John Paul II says, work is a good thing for man, a good thing for his humanity because through work man not only transforms nature, adapting to his own needs, but he also achieves fulfillment as a human being and indeed in a sense becomes more a human being through work. So work is good now, okay. An American president, Coolidge says, all growth depends upon activity and there is no development physically or intellectually without effort and effort means work. Work is not a curse, is the prerogative of intelligence, the only means to manhood in the measure of civilization. Work is what makes us human. This is about a hundred years ago. Of course there is a great definition of work in Mark Twain, right. If you remember the beginning of the book Tom Sawyer, first chapter, Tom has to paint, you remember this, who has has to paint the fence, right. And he tricks his friends to say that this is play, this is not work, this is so much fun and he tricks his friends into painting the fence for him. So Twain concludes that work consists of whatever a body is obligated to do and play consists of whatever a body is not obligated to do. So work is what we have to do, play is what we want to do. I shouldn't have changed the order here because this is Marcus. Of course, Marcus is an emperor of Rome around the year 150 and most powerful man between London and Baghdad today, it would be, and he basically talks about how hard it is to get out of bed in the morning. So I have to get out of bed in the morning to give a lecture in a, you know, in a psychiatric meeting at eight in the morning on Monday. But Marcus says you have to rise because what you go about to do man's work that I'm steered up. I have to get out of this warm bed because I need to do my work as a man, as a human being, I need to be a human. So Marcus, this is the stoic perspective, Marcus. Of course, I'm going to pass on quoting Toni Morrison, but Toni Morrison has another perspective. She's thought that whatever the work you do, do it well, for the boss, not for the boss, but for yourself. You make the job, it doesn't make you. Your real life is with us, your family, and you are not the work you do, you are the person you are. Toni Morrison is extremely wise, and we should remember her words. But what I'm giving you are all these different quotes here, different perspectives of looking at work. And finally, I'm going to finish with this. Who recognized this? Okay, a few people here remember Dire Straits in their song, Money for Nothing, right? So this is a song that the Dire Straits writer wrote when he was in a store, and there was a video of him playing, right? And the workers in the store are saying, that didn't work, this is just plain music. And the whole song is about work for nothing. The funny story behind this is if you listen to this song, which is a great song, and you should listen, you're going to hear Sting singing back vocals. Sting did that because he was friends with the band, and he told the band, you don't need to pay me for that, I'll just do the back vocals. And his agent said, no, no, no, no, no, if you're singing, you're going to get paid. So Sting said, yeah, that's money for nothing, because I'm basically just doing the back vocals here, and he'd probably make more money than I ever be made on that song by doing back vocals. So money is what we define, work is what we define work is. And we need to think about work. Let me show you the literature on work from a sociological perspective, and I'll finish my talk. If you want some, these are the books that I read to be here with you today, it's 20 minutes. All right, really quick, of course, the first one is Bullshit Jobs. So if you haven't heard that word yet on a talk here at APA, you just did. So Bullshit Jobs is a very interesting paper, book about meaningless work. And his point is that our society is proliferating meaningless work, and that we are seeing, part of the reason we're seeing this increase in mental disorders has to do with the increase in meaningless work. You see, I'm trying to say meaningless. There is another work, famous classic work in sociology called When Work Disappears. So this is a fascinating study of when work, looking at communities where most of the adult population is not working. So what do you find in that community? You find violence, crime, substance use, and homelessness. So it seems to be interwoven with work. There is a great social anthropologist called Juliette Shore. She wrote two great books about work. One is called The Overworked American, and the other, The Overspent American. And this is, part of her point is that we work too much, we Americans, and there is data to show that. We work more hours than, right now, a whole lot more hours than the Germans, which are the people that work most hours in Europe right now. Americans work more than that. There is a great book by a philosopher called Algini called My Job, Myself, in which he talks about the role of work in creating your sense of identity, of who you are. There is a very recent book called Men Without Work that talks about an interesting phenomenon in the United States today in which about 12% of men between the ages of 24 and 54 are not working or studying. There is a history of work, and there is American made, what happens to people when work disappears. These are all books written about work, work in America today, the effect of work in our lives, and the effect that work can do in our living. I do have, for the positive psychology side of this, psychiatry side of this, I would like to make sure that we can make work better. There are different ways to make work better. The first is to tell people why they do what they do, a sense of purpose. Let people have time outside work for their families. Find a rabbi, or find a mentor, or find a sponsor, whatever you want to call it. How to hire and work on our own biases against people. Treat people equally and fairly. I think that's paramountly important. And if you are a boss, you set the example to people on having a flexible and balanced life that you enjoy what you do, and you see a sense of purpose in there. So with this, I will thank you for your patience and your time with my thinking about work here. But I hope I left you with this idea that as psychiatrists, as clinicians, we ought to ask people questions about what they do, about how their work is going, and how their work affects them. And I think we have important work to do about work as mental health professionals. We have about... Thank you so much. Thank you so much. End of talk. I want to open the floor to questions. There are a couple of questions from the staff, but if you are here, you can... If you use the mic, you go. You guys come. Dr. Dilip and Dr... Tell us your name and tell us who the question is directed to. And then if you speak to the mic, the online audience will be able to hear you. Thank you. Good morning. My name is Brent Menninger, and I'm from Overland Park, Kansas, where I practice psychiatry. I don't exactly have a question. Well, okay. So the question is... I'm going to make a statement. So you talked about the skier and the trees, and I'm a mountain biker, and we're out there in the trees. And the statement, don't look at the trees, which you did not say, is like saying, don't think of purple elephants, or don't think of dancing purple elephants, so there's no such thing as a negative goal. And the way down the mountain is through the trees, on the path, so eyes on the path. But if you hit a tree, it really hurts. And they're... Right. So they're very unforgiving. Okay. So one of the practices of the skier-mountain biker is eyes, that your eyes go... No, the bike goes where the eyes go. Your bike will go where your eyes... So it's very attitudinal and very observational. Okay. But the point... Okay. So psychiatry and positive psychiatry is the focus. And we have to negotiate pathology. We have to... People gotta pay their bills, people gotta show up on time, all the things that drag us down. And so the vision is on the wellness and the wholeness and health, but darn pathology gets in the way. Yes. I so appreciate that. And I do think that kind of both end, the both end point is so important in how one's gaze actually does affect where one goes. And you're making me think about how we're... Traditionally psychiatry has focused so much on the past and what has happened. And that maybe, is it important to be considering having more of a future orientation? What does that look like? And how your gaze looking down the mountain, if you're a skier or a mountain biker or down the path, actually is informing what we do. So if we're so focused on that bump behind us, are we able to look ahead? And actually looking at positive interventions that can help us establish a better future orientation. Because some would argue that depression and anxiety, especially, are distortions of the future, that we are misrepresenting what the future could be. And if we could be, if we can help our patients be... Our brains are predicting machines, we're constantly sort of trying to look ahead. But if we can think about ways to help them, and there are some interesting studies, maybe next year we can present on those, on the future orientation. Worry is apprehensive expectations. Perfect. Yes. Thank you for the question, and I agree with what Samantha said. I'm also thinking that when we talk about positive psychiatry, that doesn't mean that we don't think about the negative things. I think what is needed is a balance. For example, extreme optimism is not good. We know that teenagers who are extremely optimistic are more likely to die, because they can run out of a train, and then they will be fine. They will not be fine. They will be killed. So extreme of anything, extreme compassion is bad. I mean, if I give everything away, I have nothing left, I won't survive. What good is it? So I think what is needed is a balance. And the problem with the way we practice medicine today is that we focus almost exclusively on the negative things. So what we are saying is that don't do that. Also think about positive. But we are not saying that stop thinking about the negative things. No, we have to think about the negative things too, and what we need is a balance. So we need optimism, resilience, and so on, but we also need to know that they have limitations. Thank you. I will get an online audience question that I think came up when Dr. Jesse was talking. Could you elaborate more on prescribing social activities? Yes. So social connections, as I said, evidence has shown social connection is the most important social determinant in terms of effect on longevity. More important than almost any other factor that's been reported. But it is not the number of connections that is important. What is important is the quality of relations. And that is actually well exemplified between how the younger versus older people handle COVID. So when the COVID started, I'm a geriatric psychiatrist, and when the COVID started, the news was all bad for older people. That much higher risk of dying, physical complications, et cetera, et cetera. Also the other problem in the social isolation was necessary for stemming the spread. Younger people were not too much affected because they had social media. They had FaceTime, Facebook. They could do that. Older people didn't have that. So the expectation was that older people will do far worse in terms of anxiety, depression, suicide. You know what the data showed? Younger people between 18 and 24 were five times more likely to have depression, stress, and anxiety than people over 65. Why? Not because older people have far fewer connections, but the quality of connections was so much better. They may have one or two connections. And so what we need to stress is not increasing the social network, improving the quality of the social relationships. Along those lines, I'd like to just think about, I mean, this isn't a pediatric child psych session, but just the data is really convincing right now looking at it's not just COVID that affected young people's mental health. It had really started declining dramatically since 2012. And it really does seem to go hand-in-hand with social media use and the actual handheld device in their hands. And so interestingly, you're seeing almost this hockey stick-like bump in depression and anxiety. You're not seeing the similar uptakes in schizophrenia or bipolar illness. It really is depression and anxiety. And Jean Twenge has written extensively about this. Jonathan Heights writing another book on this, though. And that it is almost a public health intervention that we need to do is to get those handheld devices out of at least social media away from young children until age 16. And just to promote, because it's exactly that social connection. They are alone together. They're not talking to each other. They don't know how to negotiate, how to be in a playground together. And that's probably what's so important for a free society and a democratic society is how do you talk to people you dislike? How do you argue as though you're wrong but listen as though you're right? So I think that that is also a huge part of the mental health issues we're seeing right now in young people is the lack of social connection and how are we going to bring that back. And I think psychiatrists are really well-positioned to do that and to talk to parents about how they can help do that, too. Hi. I work primarily in a university counseling center. And so I am working with all primarily younger people. And I just want to follow up with a social connection again about what you do when you're working with that individual in your office who's pretty isolated. I do try to explore what their world is like, where they can find a connection. Is there anybody in a class you can talk to? Is there, you know, if you go to the cafeteria, what kind of groups, your spirituality? But it's just so common that everybody I'm seeing is feeling alone, you know, and it's everywhere. You know, yesterday in an Uber ride talking with a Jordanian immigrant who says, you know, I see people everywhere and I'm completely alone. You know, yeah, I can find a hookup for sex, but in terms of finding some meaningful connection, it's, I think for people who are connected to a church or maybe they go to a senior center or things like that, but I'm finding in the university culture, it's really hard for students to find, I mean, and they do, obviously, a lot of people, you know, they really find meaningful connections. But the people I'm seeing, it's really a lot of work to help them start to make some steps towards, you know, get coffee or go to lunch or whatever, you know, it is. And I just want to throw that out there and see if you have thoughts and suggestions. I think you make a great point. And I think the meaningful connections is what matters. And once again, as Eric said, the job, what matters is how much meaning it has for you. And because the social connection, they don't depend on the number, as I said. But I'm actually thinking about how do we define social in social connections, right? Typically, we think about connections with another person. But what if I have a pet and I love my pet and I don't need anybody else, that pet becomes my friend, that becomes my social connection. In Japan, robots have become very common, especially in older people. And robots often, they're increasingly becoming best friends. Of course, the robots are getting better. So they're not just, you know, Siri-type things. But increasingly, they will become more human, humanoid, obviously. So isn't that good enough, social connection? Going even beyond that, you mentioned about religiosity and spirituality. So if somebody believes in God or spirit, something like that, then they would feel constantly connected. They don't need another person. So when we talk about social connection, it is not necessarily with other persons. It can be with another animal. It can be with a robot. It can be with some imagined connection, including spirit or religion. And there's nothing wrong with that, right? If that is meaningful to you, that's what matters, right? Absolutely. And I'm thinking of Isaac Prilotensky's work when he talks a lot about mattering, like what does it mean to matter? And his theory is that we need to feel valued, but we also need to feel that we're adding value. And to matter, you need both. And so what are those ways, especially for those younger people? They have tons of connections. They might have thousands of friends on Facebook, but they feel unbelievably lonely. Very few people that they report they can have a meaningful conversation with. And actually, it brings back some philosophy to me. I think it was Aristotle who said there are three types of connections that we have, or friendships. We have those that the people, I do this for you, you do this for me. They're very transactional. The second kind being, you know, we have a good time together. We're fun. We go to a frat party together in the college context. And the third is the ones that sort of elevate you and the ones that sort of, you know, you feel like you're adding value to their life and they're adding value to yours. And how do we sort of create more of that? I do think in prescribing, and maybe prescribing sounds too heavy-handed, but actually that sense of where are those pro-social activities, where can they feel that their experience matters, that even giving advice to younger class people coming in as freshmen, you know, what was hard for you? What was challenging for you in this situation? Because not only is that helpful to the recipients of that advice, it actually, there's research that shows that it can help them feel that their experience matters to somebody else. Let's get a next question from the audience. Yes, more of a comment, and I appreciate, you know, the questions asked. Recently, I work in New York City, and there are a lot of very lonely and isolated people who work 18-hour days in New York City who are extraordinary individuals, and they don't even know their next-door neighbors who are extraordinary individuals. Recently, I've discovered the contributions of American cultural anthropologists from the 1970s who studied nonverbal communication. And they were telling, back then, they were telling psychoanalysts that 70% of how we communicate is nonverbal, and 30% is verbal. So what I do with my patients to go from isolation to deep connections with others is that I emphasize the importance of a smile on your face, the importance of small talk, the importance of exposing yourself to groups of people. Even if there is no verbal interaction at the beginning, you know, to think of that as a transitional step towards that. And it works so well. I mean, I remember this one particular patient that I gave her an exercise. I asked her to smile for two weeks almost all the time, whenever she's on a bus, on her way to work, just to see what happens. Two weeks later, she comes to a session. She told me that this young man in a bus smiled back to her. They started a conversation, and to make a long story short, you know, they're together now as a couple. And, you know, she had migrated from Arkansas to New York City to work in a high-power bank, high-power position, always in front of a computer, and was one of the loneliest people I have ever seen. But, you know, a very verbal, very smart, very profound individual in all her ways. So, you know, I think it's important to, you know, coach. I'm a psychoanalyst. You know, I'm being very directive with my patients. To coach our patients to understand the evolutionary purpose of small talk. I actually say this to patients. It's important that you talk in the elevator about the weather. You know, you really never know what the third or fourth conversation with that neighbor will take you to. So, you know, I think we need to be sort of pragmatic when we're trying to get our patients to move from isolation to intimacy. And, by the way, you know, in terms of the other comment of our field being too connected to uncovering the past, as a psychoanalyst, the way I put that into a meaningful context to our patients is that, you know, yes, past life experiences are linked to our present predicaments. But the whole purpose of that connecting past with present is that you can have a better future so that you have control over your future. And if that is the greater context, then people do not mind looking back in time to then understand how they can have a better future. Sorry to take so much time. Thank you. Thank you, Cesar. I should mention that Dr. Cesar Alfonso is the president of the World Federation for Psychotherapy. And... No, I think your point about nonverbal communication is great. I mean, there's no question about that. And I'm not a child psychiatrist, but I know that the mother-child attachment is probably the best model of any interpersonal relationship. And it is a nonverbal communication between the mother and the child that matters far more than the things that the mother says or vice versa. And numerous studies... Actually, again, I'm learning this literature. But numerous studies have shown that that attachment determines your subsequent relationships. And that sets a role model. And that's why if there is a bad parental relationship in early childhood, that becomes one of the biggest traumas in the rest of the life. And that's where, again, psychotherapy can come into play when you can try to remove the negative effects of what happened in earlier life. But that's a great question. Thank you so much for those points. I love what you said about strangers. And it's true, I think we often are thinking when we're talking about social connection, it's got to be family, loved ones. And lots of research showing that... Just as it was so difficult about COVID, that person walking down the street that you would interact with. But also because of our devices, there's definitely fewer random social interactions when we're looking up, smiling at somebody on the bus because we're so buried in our phones. And how as human beings, we get this wrong all the time. When they survey people and they ask them, would you rather keep to yourself or talk to the person next to you, even on the subway in New York, which can be a scary thing to do, people assume that they'll feel better if they can get their work done, return their emails, but actually know they're going to feel better when they're in that interaction with somebody. Even these micro moments of connection with the barista, with a stranger. And the other point you made about non-verbal connection is the experience of felt love. It isn't just the idea of someone saying, I love you, but actually when you feel it as a child, as a parent, as a friend, what does that look like? And just those experiences, those gestures that occur in our everyday lives that sort of bond us to others. And it's work from Shelly Gable, looking at what she calls active, constructive responding to somebody, ACR, is when you respond to somebody who tells you something or wants your attention. You can look up, you can give them your full attention, you can look back at your phone and be like, yeah, what's for dinner? You know, you can say, oh, and just sort of turn away from them. Are you turning to that person or are you turning away? And it doesn't have to be verbal. It can very much be in the presence, how you're holding your body and how you're interacting. So thank you so much for that and also your point about the past and the future. I just want to give the online audience a quick shout out. I think they're asking some very good questions that if we don't have time to answer, it's 9.30, so I'll just share the questions with you. Could you give some examples of encouraging using strengths? That was for you, Samantha. Somebody said happiness presentation, which I think is a happy thing. Then somebody made a comment. Dr Merenkov made two comments. In our capitalist world, with our worth tied to money and consumerism, how can one utilise principles of positive psychiatry to find something more meaningful to offer patients or ourselves? Point. And the next point was how do you balance this focus on positive principles with the importance of giving objective feedback, even if hard for the patient to hear? Cannot facing our flaws, vulnerabilities, if done sensitively, also motivate us towards developing meaning? And then somebody said, for me, encouraging hobbies and engaging community volunteer activities that are aligned with the person's interest have been very effective. So I think those are very good comments for us to take with us. We can continue this conversation if you guys have further questions. Thank you so much for your time today. Thank you.

positive psychiatry

mental health

psychosocial determinants

social connections

Dilip Jeste

Samantha Brodman

resilience

cognitive behavior therapy

social skills training

healthy lifestyle

personal strengths

social engagement

psychiatric practice