Social Prescribing: Turning Community Into Medicine (Full Transcript)

[00:00:00] Speaker 1: I'll give you an example of a patient I spoke with named Frank. Frank had been dealing with type 2 diabetes. He was a truck driver, and he was told he was going to be on insulin for the rest of his life. But then when he went to this doctor who really believed in social prescribing, he found out that Frank used to love cycling. He prescribed Frank a spot in a 10-week cycling course. He falls in love with cycling. He creates a WhatsApp group to keep on cycling with the people in the group. They call themselves the Chain Gang. Frank has lost 100 pounds. He's come off his insulin, but more importantly, he's not lonely anymore.

[00:00:42] Speaker 2: I was really looking forward to talking to you because I am fascinated with this idea that, you know, as a doc, we think of prescribing things, and they think a pill, they think a procedure, but you're talking about something else here.

[00:00:56] Speaker 1: That's right. This is literally, Dr. Gupta, a social prescription. The idea of your doctor, your social worker prescribing you something social in your community, like an art class, like bicycling lessons, the same way they would prescribe a pill. And the idea here is, you know, we know that connecting with others is good for us, moving our bodies, paying attention to nature. What's new here is the idea of connecting that to how we do medicine in the form of, let's say, a 10-week nature workshop to address a specific symptom within us.

[00:01:36] Speaker 2: You know, I don't think anyone questions that these things have value. But I think the thing about prescribing something that's a medicine is that it has data behind it. You do these trials. You see what works best for who, all of that. What about here?

[00:01:52] Speaker 1: That's exactly it. I mean, exercise is pretty non-controversial. For 50 years, doctors have been saying exercise for social connection increasingly is part of that. We are understanding the way that strong social relationships is one of our greatest predictors of longevity. Now, there have been art therapists and nature therapists who've also long known the health benefits of nature and art. The idea is here to have all kinds of disciplines from your family doctor to your mental health counselor actually being able to prescribe you something that encompasses those things because we know that these are effective and they require more than just a doctor's recommendation. We need that accountability and we need that sort of built-in intrinsic idea. The catchphrase of social prescribing is shifting from what's the matter with you to what matters to you.

[00:02:54] Speaker 2: I love that. Everyone should just let that settle in for a second. Not what's the matter with you, but what matters to you. I have been sort of fascinated by this idea that when they do these images of people who identify as lonely or as isolated. And I say identify as because people may be surrounded by other humans and still identify as feeling lonely or isolated. But what I found really interesting was that the same areas in the brain that are responsible for physical pain overlap heavily in those people who say that they have feelings of isolation. So the idea that that feeling of isolation can physically hurt, it gives people the sense of the fact that there's measurable things that happen in your brain when you are not socially connected.

[00:03:46] Speaker 1: I mean, isolation and loneliness is some of the greatest social pain we can experience. And it's not just in our heads because if you think about it, evolutionarily, we needed to have a people, a tribe around us. There's a great evolutionary psychologist I love, Dr. Arthur Aaron, who talks about our evolutionarily rooted need to connect as being a function of knowing ourselves. So we know that when we have a really good friend, someone really close to us, they actually help us understand ourselves better. And this is evidenced by things like Harvard study of adult development, which found that social relationships were the greatest predictor of health and longevity. So just as it's true that isolation, feeling a lack of companionship, we think of it, we could think of it as hunger. It's signaling our brain to reconnect. The opposite is also true, that when we feel a strong sense of belonging, we are protected from physical and mental ailments in ways that we wouldn't be had we not had those connections.

[00:04:58] Speaker 2: How do you know if you're somebody who is in that position? I mean, a lot of people may sort of say, yeah, I get, you know, I'm lonely from time to time. I have a few friends. Is there a point where you say, yes, this person needs a social prescription?

[00:05:15] Speaker 1: I would say that for most of the rollout of social prescribing, which, by the way, is now happening in 32 countries, including the U.S., it starts with what we recognize as more clinical symptoms. I'll give you an example of a patient I spoke with named Frank. Frank had been dealing with type 2 diabetes. He was a truck driver, and he was told he was going to be on insulin for the rest of his life. Frank wanted to change this. And when he went to doctors, oftentimes they told him, you have to exercise more, you have to eat better. And that's where the conversation stopped. But then when he went to this doctor who really believed in social prescribing and asked that what matters to you question, he found out that Frank used to love cycling when he was a kid, and he also found out that by virtue of his job being a truck driver, Frank was really lonely. And so what did that doctor do? He prescribed Frank a spot in a 10-week cycling course. They also gave him a free bike because he hadn't had a bike. What happened to Frank in that time? He goes to this 10-week course. He falls in love with cycling. He creates a WhatsApp group to keep on cycling with the people in the group. They call themselves the Chain Gang. They've been cycling every week together for four years now. Frank has lost 100 pounds. He's come off his insulin. But more importantly, he's not lonely anymore. And so that just illustrates that, you know, Frank might not have, you know, really resonated with the idea that he was lonely and needed a social prescription. He went in there for help with his type 2 diabetes and obesity. But because the loneliness had coexisted with that, the other side of that, I think, was that, you know, in order for Frank to exercise better, to have some motivation, he needed social connections as well. And so I think for a lot of people, loneliness is grouped in with these other things.

[00:07:19] Speaker 2: What are some of the other health conditions? I imagine for really acute problems, you know, strep throat or something like that, we're not talking about social prescriptions there. If anything, maybe you don't want to be social if you get a potentially contagious virus. But what are other things besides diabetes?

[00:07:38] Speaker 1: That's right. Social prescription for strep throat, maybe not. But we do know that our recovery time for things like strep throat or the common cold are influenced by our inflammation. And so, you know, maybe next time you have strep throat, if you want to do a little drawing workshop with YouTube, have some buddies on to Zoom, that could really help with that. But in the book, you know, I mainly talk about, you're right, chronic conditions, everything from lifestyle-ness, like type 2 diabetes, to depression and anxiety. I talk about how it supports people with addiction, people dealing with dementia. Up to 80% of our health is impacted by social and environmental factors. And particularly as we're seeing higher and higher rates of chronic illness, of lifestyle illness, of mental illness, you know, there is a need for more solutions other than the ones we've been given, because clearly if the rates are going up, they're not doing their job fully. So you know, I talk about, for example, the story of this woman, Amanda, dealing with major depressive disorder. She ends up getting prescribed a spot in this 10-week sea swimming course. And you know, she had never been swimming before, especially in the cold conditions in which she does it, which, you know, if you're here in New York today, it's a cold day. It's hard to imagine anyone swimming today. But that's what Amanda did. She does this 10-week sea swimming course. She's moving her body. She's enjoying the natural, you know, settings of being in the sea. Most importantly, though, is she's connecting with her people. And she went from the maximum dose of her antidepressant to the minimum. So that's just an example of, you know, this can help with so many different conditions and more than just kind of self-reports. This is, in some ways, lowering our reliance on medication and, you know, having those clinical outcomes that we would want for other forms of medication.

[00:09:47] Speaker 2: Why does it, you know, some of these things seem pretty basic in the sense that, you know, we know we should have connection with other humans. We recognize the benefits of it. And yet we're talking about prescriptions here. We're talking about a doctor writing a prescription for this sort of thing. Why is it different coming from a doctor versus just what you should intuitively know?

[00:10:09] Speaker 1: You know, number one is that people tend to trust their doctor. Doctors have very high levels of trust. And so when your doctor is telling you, hey, you know, 20 minutes in nature, and your doctor is then citing all of the clinical benefits, such as reduced blood pressure, less cortisol production, better attention benefits, that sort of clinical value is going to hit a little bit harder. So one is about the authority. But the second part of that, I think, is about the prescription. So it's not just your doctor telling you you need to exercise more, you need to spend time in nature, but it's your doctor and their team actually referring you to a specific time and place that does that thing that you're a little bit interested in, and they're going to follow up with you to see how it goes. So in that sense, I think a social prescription, you know, combines all the things we kind of know about human behavior. We need to be held accountable to do things. We need to have some inherent motivation. And we tend to follow the data. So I think social prescribing is really about combining those things into a practice that makes sense in, you know, what health care has traditionally done.

[00:11:27] Speaker 2: So when you then look at data, are people more likely to stick with something like Frank and a cycling program if it comes as a social prescription versus just as a nice to-do thing?

[00:11:39] Speaker 1: That's exactly it. I would say that Frank is the rule more than the exception. And that is the point. And you know, people might be listening to this and wondering, why would health care invest in this? How does it make sense, particularly in our U.S. health care system, for people to invest in a cycling prescription? Because it often leads to lifestyle changes that come from the 10-week, let's call it a trial. And you think that if you're an insurer and you have the option to either, you know, give somebody pills or cover surgeries or cover therapies for the rest of their life versus a prescription that might lead you to meet people and rediscover a healthy habit on your own, then the social prescription makes a lot more sense if, you know, people end up like Frank did. And many do.

[00:12:29] Speaker 2: So Frank, again, just sticking with him. So he got this cycling course and he got a bike. Was this something covered by insurance or who does end up paying for this?

[00:12:39] Speaker 1: So that's a great question. It's important to say here that Frank is in the U.K. And the U.K., like many of the countries I went to, have a nationalized health care system, which therefore means they have an incentive to improve health outcomes and reduce pressure on health care. So social prescribing is a national investment there. And there are funds now for practices to, you know, implement social prescribing programs, whether that's paying more staff, they call them link workers, to actually help with having those what matters to you conversations, executing the prescription, as well as for covering the needs and resources in communities such as the bike. In the U.S., it's true that we have a very different health care system, but there are parts of it that resemble the U.K.'s, such as Medicaid and Medicare. And in those systems, I would say that in the U.S., that is where we're seeing the most social prescribing uptake. In the same way that you might have an insurer that covers the cost of your gym membership, we're seeing that more and more with things like art classes and cycling lessons. Based on that same logic, that this is actually going to reduce costs over time.

[00:13:49] Speaker 2: And you're talking about things that are complementary to medicine. So going back to Frank again, no one is saying that that bike course is going to replace his insulin necessarily, but it may reduce how much insulin he's dependent upon or drop weight, whatever it might be.

[00:14:07] Speaker 1: That's exactly it. And I think that is the way we want to frame this, you know, that this is another option we should have on the health care menu. I mean, let's take Amanda. She didn't stop her antidepressant. She had this as an adjunctive therapy, was able to reduce her dose. She's still on it. But I think that that is obviously a benefit economically to be paying for less medication, less insulin, you know, less antidepressant. I think that that's not always the explicit goal of social prescribing. The goal is for people to feel better and to, you know, maybe over time use fewer health care resources. But it's really about just feeling better in the short term and, you know, letting all the rest kind of catch up with that.

[00:14:53] Speaker 2: You know, I had a really interesting thing happen to me, Julia. During the pandemic, I was working on this book about the brain and I was talking to one of my old mentors, somebody who taught me a lot about neuroscience. And he made this offhanded comment about something he suggested I do, which was to take up painting and to predominantly paint with my non-dominant hand. So I'm right handed, but he suggested I start painting with my left hand. And first of all, I'm in my 50s and he is my guy. And he's saying, here's what I want you to do to improve your brain health. And it's really fascinating how much you can change your brain through things like that, which I imagine is the same with an art therapy, sort of social prescription, whatever it might be.

[00:15:41] Speaker 1: Absolutely. I love that. I would love to see. Are you keeping up with it? Oh, yeah.

[00:15:46] Speaker 2: Yeah, I am. I'll send you some pictures. And the funny thing is, you write a book like this and I wrote about that in the book and all these people will send me their artwork, they'll send me pictures of their artwork, which is really pretty, pretty cool. Erin Burnett, who's one of our anchors here at CNN, she got into it and she was sending me her artwork periodically. So it's really interesting.

[00:16:06] Speaker 1: Absolutely. You know, and I think, you know, the two examples I shared about Frank and Amanda, type 2 diabetes and depression, these are things we we tend to relegate to physical health and mental health. But for brain health, I saw so many examples of social prescribing success stories, particularly for older adults, where, you know, what you're saying about being able to stimulate these pathways and maintain sort of neuroplasticity. And a story I love to tell about this comes from a choir in Ireland for people with Parkinson's. Now for people with Parkinson's, as you know, you know, you may start to lose some of your abilities around movement, around speech. And what they do in this choir is they meet every week, they do a bunch of, you know, physical dancing exercises, and then they sing songs. And there was this one gentleman named Mike, who for a very long time, you know, they couldn't have a conversation with him. He had lost his ability to speak. But if you can believe it, by being in this choir, he actually regained his ability to sing. And that was now his form of communication with other people. So it's just incredible the way that I think social prescribing, just as it does for your non-dominant hand painting, is kind of revealing parts of ourselves that we might not have otherwise known and that are actually quite joyful with, you know, other people who are just as into it, kind of based on an activity you're already interested in. I think that's where the sweet spot is.

[00:17:51] Speaker 2: What about in-person versus digital or Zoom?

[00:17:56] Speaker 1: Yeah, I hear that a lot. And I think for many people, you know, there is sort of this stigma with online gathering. But I like to tell a story about a veteran I interviewed in my book. He's 92 years old. He doesn't have a car and he doesn't really have the option for in-person connection. He gets linked up with a volunteer phone call buddy, 50 years his junior. And the two of them just develop this awesome friendship through these weekly phone calls. So I would say that for people who can't or don't want to leave their house, virtual online is absolutely a great substitute. That said, you know, I think that there is something to all of the kind of side benefits that come with leaving your house, you know, walking to a destination, exploring a novel environment that, you know, can just really benefit our health in all these unprecedented ways. But I would say that for social prescribing, it's important to think about the limitations and the access challenges of certain people. And both are really important.

[00:19:08] Speaker 2: Yeah, I think we're probably going to learn a lot more about that as time goes on. You know, I have three teenage daughters and, you know, they do spend time on screens interacting with their friends. And I especially did that a lot during the pandemic. And I remember thinking, this is better than not having any contact. But I don't know what percentage, like, is this 50% of that? Is this 70%? It's not 100. But what percentage good is digital? There's probably not an answer to that.

[00:19:43] Speaker 1: I will say it's a great question. How you're using those screens is important. You know, are you mindlessly scrolling on a feed that's convincing you to buy more stuff and maybe lower your self-esteem in some ways? That's one thing. But if you're on the phone, catching up with your friends or in a group chat, and you're sort of strengthening those connections, strengthening that sort of, you know, self-expansion that we talked about, this idea of people you're connected with actually helping you get to know yourselves better, I think that's great. And I think that what I've often heard said in the context of young people is it's also about what is being replaced. So if all that screen time is replacing sleep, exercise, time in nature, that's a different conversation. Right.

[00:20:29] Speaker 2: Some of what we're talking about on the podcast today is more mainstream in Norway, Scandinavian countries and the UK, for example. Why has it been slower to catch on in the United States? And do you think that whatever those reasons may be will make it harder overall for it to catch on in the United States? Or is this just a question of when, not if?

[00:20:53] Speaker 1: Yeah. I really, truly believe this is a when, not if. I mean, let's talk about the challenges. Like we said, our health care system doesn't look like the health care system of any other place in the world. So I think starting in the places where our health care system does look like other places in the world, such as with Medicare or Medicaid, where there is this natural incentive to improve outcomes and lower the cost of care is really important. I'm hopeful about the way that we are culturally recognizing that social connection is really important for our health. It's not just a nice to have. My hope is that we say the same thing about art and nature in 50 years that we now say about exercise. I just think we have to have the systems be built to allow this to happen in our very unique health care system. Yeah.

[00:21:46] Speaker 2: And I will add as well, I think, you know, some large corporations have started to see the value of what you're talking about. And you know, to be totally candid, they want their employees not only healthy, but as efficient and effective as possible and incorporating these things into their life can be helpful in that way. So look to your to your own company's websites, go to a lot of the uptake of health services within large corporations is really low, usually in the single digits. So employees can definitely find things that might be helpful there. And I think probably also helping make a dent in what is a significant epidemic of loneliness as well. So not everything you've talked about necessarily requires another human being to be involved, but many of them do. And I think you get a lot of those benefits from that.

[00:22:36] Speaker 1: What's exciting about social prescribing, particularly after a pandemic and lockdown where a lot of us kind of forgot how to socialize, is this idea of you're doing something with other people and the socializing kind of happens naturally. And there's ways to make this work for people of all kind of personalities, whether they're more introverted, more extroverted, more socially anxious, less socially anxious. It really all comes back to that. What matters to you? Start with that. And then the socializing will follow.

[00:23:13] Speaker 2: You know, during the pandemic, I think I had a sort of revelation about myself, which I think fits into this conversation. And that is, to be quite honest, I never think I really saw the value of socialization. I thought it was nice, but that was it. I thought it was a nice thing to have, not a necessary thing to have. And then what happened? I didn't have access to it anymore. And I realized I missed it. And there's so much about just spending time with other humans if you want the mechanisms of releasing certain hormones in the body and what that does for your brain and your body. But I think it's also about this idea that we're constantly trialing our own thoughts. And you know, like we're working our way through the world, even as adults and having someone else to just sort of bounce ideas off of and play around with thought bubbles and things like that. And anyways, I missed it when I was in the middle of that pandemic. And now I've tried to make it a big part of my life. So if you were to ask me what matters to me, as opposed to what's the matter with me, I'd probably answer along those lines. The idea of simply being around other people gives me context for life. And that's really relieving of my anxiety. How about for you? Absolutely. I'm sure you thought about, not what's the matter with you, Julia, but what matters to you?

[00:24:43] Speaker 1: Absolutely. When I'm really burnt out and overwhelmed at work and feel like I can't pay attention, it's birdwatching for me. I go to my park, I sometimes text other people to join. And there's something about you have to be looking up at the birds that's so magical. I dealt with migraines and, you know, headaches for a while. And I was so inspired by what I'd heard from one of the chronic pain doctors I interview, which is that she asks people to talk not about when their pain is the worst, but when it's the least. Like, what is in place in your life when you are feeling the symptoms the least? And sure enough, it's when people are, you know, connecting with other people, they're reconnecting with a hobby. That's not to say that their pain isn't real, it absolutely is. But I think that applies to most conditions in the sense that there are environments we could put ourselves in, and hint, hint, they often involve other people and things we love, where our symptoms are less and we feel better.

[00:25:50] Speaker 2: You know, what I love about your book, and by the way, everyone should read this book, and you should also go to page 325 and answer the questionnaire there, because I think what you're trying to get people to do is figure out what matters to them. It's a simple question, but I think it has a more complicated answer than I think people realize. What really matters to you, it's worth going through the exercise to figure that out. So I really encourage people to do that. And I'll send you some of my left-handed paintings.

[00:26:19] Speaker 1: Yes, please do. You can tell me what you think.

[00:26:22] Speaker 2: Thanks so much, Julia, really appreciate your time.

[00:26:25] Speaker 1: Thank you so much, Dr. Gupta, such an honor.