In one of the breaks at the 12th Conference on Personality-centered Medicine in Geneva on the subject: “Promoting Well-Being and Overcoming Burn-Out“ I had the opportunity (donated to me by Professor Drozdstoy Stoyanov) to talk to Professor C. Robert Cloninger. This happened on March 26, 2019. He is a contemporary personality theorist. He holds the Wallace Renard Professorship of Psychiatry and is a recognized worldwide scientist in the fields of psychology, psychiatry and genetics. The conversation involves presenting his work and professional experience in the creation of psychobiological theory, as well as the integrative approach he develops. Burnout syndrome is also interpreted in the context of his views. It is an honor for me to share his perspective in my preferred format of the interview, because while I am in my field of professional search, I succeed in touching the professionalism in the warmth of the human situation.

Kristina: If you had to describe yourself in a few words, what would you say?

Robert: In my thirties, I was an inquisitive and idealistic person who was trying to understand the biological basis of human nature by studies of psychiatry and genetics.

Kristina: Was this for your first education degree?

Robert: When I was in university, I studied philosophy, anthropology and psychology and so at that point before I entered medical school, I was really interested in the same questions that I am interested now. Once I went to medical school, I then focused more on just the biological aspects and it was only when I turned forty that I realized we could not reduce the human being to just biological genetic systems; we also had to recognize that there was a second level of character that was humanizing. As I studied a little further, by the time I was in my late forties, I recognized that I could not understand what exactly allowed a person to change by just describing their character. I then had to recognize a third level that you could call the soul or the creative mind so to speak, that allows us to develop insight. Then from that insight we can look forward to what we can create. So I found that understanding what exactly drives dynamics of change was really the third step. I basically went from an initial approach to philosophy that was very much like platonic anthropology and focused on the power of culture and looked at human beings as rather free, that is, having free will and creativity. What I had reduced in medical school to just biology, step by step, I had to reconstruct to recognize the boarder view of humanity as having body, thought and soul.

Kristina: What is the last event in your career that pleasantly surprised you?

Robert: In my own career, the greatest sense of satisfaction has to have been that I have been able to describe the nature of human beings with three aspects. I have been able to transcend a reductionistic approach to genetics by studies of the evolution of our genetic capacity of learning. I have now shown that there are actually three systems in learning and memory that evolved in sequence. It is satisfying to research all the aspects of this problem throughout my life, including the assessment, development, treatment, inheritance, and evolution of personality. I began with a broad view, and then however tried to reduce it to something simpler, which was the way that the modern society was and is trying to reduce our notion of who a person truly is, making them out to be simply molecules or genes. I found that was not adequate but I was still surrounded by people who classified themselves as biological reductionists, who somehow did not appreciate the importance of intentional or creative thought. My recent work on evolutionary genetics has actually allowed me to now prove the fact that human beings have a ternary nature (body, thought, and soul), which in itself is very satisfying. This is very satisfying because it has allowed me to show that biology contributes very much to who we are. Likewise psychology of thought contributes a lot regarding our level of attention and goal setting. Furthermore we must recognize that we are self-aware human beings and that we create our opportunities and our environment in order to express our inner potential. That is really the job that we have now, that is, to be able to use our self-awareness so that we are able to recognize that we are doing so many things in the world today that are not sustainable because they jeopardize the health of the planet and also our ability to survive as a species. So the question is whether human beings are sufficiently self-aware and disciplined to be able to correct the path that our cultures are taking us on right now and by acting responsibly with self-awareness makes it possible for us to help save ourselves as a species.

Kristina: I saw in the review with you and John Oldman (The Menninger Clinic, 2015) that you mentioned something about the human genes being like an orchestra and that it is not sufficient for us to try and understand how the genes could work simultaneously to make the orchestra play in harmony.

Robert: The question about us being like an orchestra in understanding how genetics works is a very important question because for a long time, we assumed that genes were just operating independently one at a time. That assumption is a mistake, because they do not work that way. We find that, at least in humans, the genes are highly organized by regulation of how they are expressed as clusters (like an orchestra has members who play together to create harmony). Even in the simplest of animals, genes have to be expressed together in a certain way in order to achieve functions. Even in the simplest of animals, there is a great deal of gene-gene interaction. These interactions allow us to adapt to the environment and world we are in. In other words, genes are always acting in combination with one another. What tends to happen in humans is that when we set goals, we have to change the way the genes interact in order to accomplish them. Essentially by setting goals we act like the director or conductor of the orchestra, so by forming our intentions and by changing our values, we actually are able to regulate the way genes are expressed in groups, thereby achieving the goals we have created for ourselves. We are not determined by the genes that we were born with; rather we choose how the genes will be expressed and organized. As we set our goals, we are actually able to change the way they are expressed so that we are creating our own health, future, and environment, within some limits. The reason I like to refer to the genes operating in concert and not independently is that is the best way to how we are able to create beauty and harmony. It is natural for us to strive to live harmoniously, because we actually feel good when we are doing good. Being aware of your own functionality is kind of like listening to music and seeing how it makes you feel. It is a very useful analogy, because it is faithful to the fact that our whole life is fair because it feeds back on us and if we act badly, for instance, by being angry or fearful, we are more vulnerable to get sick. We will not feel well and we will know that we must be doing something wrong that we should not be or that we are not acting in a way that meets our capacity or potential. When you do things that make you feel well or make the world more beautiful or harmonious, then those actions bring a great deal of satisfaction to you and to others around you. For life to be good, all we really need to do is aim to bring harmony and beauty into the world.

Kristina: What does spiritually cultivated mean? You mentioned it in your book "The Science Of Well Being" (Cloninger, 2004). I understand my question may be very commonly asked but what would you say the first things that springs to mind would be if you were speaking to a psychology student, such as myself who had not heard about your integrative approach?

Robert: Well, I do not see it as being too difficult because what I am trying to do is to find the basic psychological principal. Your question could in fact be converted to "how could you cultivate a healthier character and personality?". That can be done by first accepting who you are currently, because you cannot really move forward unless you know what you are standing on. In other words, the first job would be to try to look as objectively as you can at who you are and how you are functioning and feeling. From there you can then think about what directions you want to take because it is not fun looking at things you do not particularly like about yourself. Nevertheless, you need to accept your strengths and weaknesses in order to figure out what tools you have to move forward. Then there is a second step in which you do need to step back and look without judging or blaming about what resources you have and what things you need to change in order to accomplish something that seems worthwhile to you. Engaging in psychotherapy, you will never get people motivated to change unless there is something they want more than what they are currently getting in their life. With that in mind, you have to help a person to become self-motivated by recognizing something that they want to work towards. You cannot do the work for them --- they have to want to do the work. You can only help them to see who they are and what they would like to become, and from there, the two of you in a therapeutic alliance can try to visualize a path from where they are to where they want to go.

Kristina: What motivated you to adopt so many children, was it your job or could you say it was the opposite and that the children motivated you and your work? Is there any kind of synchronization between the general idea cycle and the bio psychologically spiritual theory?

Robert: Well, I think that I just really like people. For example, when I was doing nearly only research, I often had to ask for special permission to be allowed the time to see patients. I told the authorities that I did not want to be a professor who no longer sees patients and who loses his skills with patients. As a psychiatrist, the only way I can really test my ideas is to see how I can work with people and help them. So I continued to see patients throughout my career at least 15-20 hours a week. That practice without a doubt kept me humble because patients do not always perform accordingly to my theories, and I had to keep changing my theories. My clinical practice really aided me in being a better scientist and then of course such growth in insight extends into your personal life. I do not really separate my personal and professional life much; they are very much integrated as natural extensions of each other.

Kristina: What did you manage to realize about yourself regarding this choice?

Robert: Well, what I see is nearly everyone wants to be happy and healthy and have some sort of meaning for their life. Everyone experiences various kinds of good and bad luck. If you approach anyone with respect and hope for them, you will also develop faith in the human potential for people to grow and develop in a positive direction. Self-actualization is not just something that you come across in research as a professional psychologist or psychiatrist. We all need to encourage self-transcendent and self-actualizing behaviors in our friends, family and community. That is why many of us are here today at this congress to try to get a more person-centered approach to medicine. Without that, doctors are getting sick and burning out. There is a shortage of doctors already, and the loss of doctors is occurring at an alarming rate in many communities. We need to function as full human beings in every aspect of our lives in order to be healthy. We can do that by combining creative functioning, willingness to change, and awareness of self-transcendent (virtuous) goals and values. Everyone wants to be healthier and happier, but some people tell me that they are not interested in doing the work needed to change. Often people who have power, money, or fame want to maintain the status quo. Often they are not really happy and healthy, but they are unwilling to give up what they already have for something more satisfying. Such people are simply just not ready to change.

Kristina: So, in regards to the context from the congress today, from a psychological point of view, what could burn-out be compared to?

Robert: Burn out is simply an impairment in our state of well-being. Burn-out is a state of ill health that rises when people are asked to work in conditions that do not actually allow them to express their humanity. It is the result of working in de-humanizing conditions that do not respect you as a human being who has freedom of will and a need for autonomy and respect.

Kristina: My last question is again connected to burn-out. I remembered a couple of sentences from today's lecture, the first one being that human health is more than the absence of disease and secondly, burn-out is caused by a lack of well-being. Could you comment more on this?

Robert: I think one way to understand the importance of talking about health, disease, well-being, and burn-out is that if you try to correct disease, you do not necessarily create health and well-being. You can reduce the amount of pain and suffering by correcting a disease but health is actually a state far beyond the absence of disease. It is a capacity to withstand stress and injury, to be able to heal and prevent degeneration. So it is a very active state that allows you to make sacrifices to be able to accomplish things that are important. It is not always about just doing things that are pleasant, it is about being able to make a sacrifice to save another person's life or to risk getting hurt so that you can accomplish something important, maybe not for yourself but for somebody else. When we are in a state of real health where we are resilient to stress and injury, we feel satisfaction that we accomplish something meaningful and that is not simply the absence of disease. Likewise, if you focus on just trying to eliminate disease, pain and suffering, you do not necessarily create positive emotions or do all the good that you can do. In psychology, we have learned that positive emotions are not just the absence of negative emotions. Joy, contentment and satisfaction, these are all additional emotions that emerge from different parts of the brain than do negative emotions. A lot of our emotional brain, which we share with animals, have automatic responses for fear, anger, and other negative emotions. Positive emotions and altruistic behaviors arise from higher parts of the neocortex that evolved only in human beings. Only human beings have the capacity to feel joy from doing something that may cause them pain and that is a very unique ability that I think is fundamental to our humanity. This allows us to be healthy and have a long life, which in turn allows us to be dedicated to helping our children and grandchildren and also the community of which we are a part. If we are not managing to live with such love and hope, then we are not really living life to the full and we are not taking advantage of our full human potential.