Delve into the transformative potential of psychedelic-assisted psychotherapy with Andrew Penn, a leading expert in the field. We explore the importance of "set and setting" in creating an optimal therapeutic environment and discuss the gradual, glacial changes that can occur through a psycholytic approach. Andrew shares insights on the impact of psychedelics in fostering personal growth, addressing depression as a disease of disconnection, and the practical considerations for clinicians interested in incorporating psychedelics into private practice. Join us for an enlightening conversation on the future of psychiatry and the practical implications of psychedelic-assisted therapy.
Join us in this captivating episode as we explore the transformative potential of psychedelics with our guest, Andrew Penn, a registered Psychiatric Mental Health Nurse Practitioner (NP) and expert in the therapeutic use of psychedelics. We delve into the concept of small psycholytic changes versus monumental breakthrough experiences and the need for further research in this area. Andrew emphasizes the crucial role of set and setting in creating a safe and supportive environment for psychedelic experiences, and discusses the importance of cultivating a sense of safety.
We also delve into the impact of psychedelics on changing our relationship to illness, particularly depression, and how they can provide a profound sense of interconnectedness. Throughout the episode, Andrew shares practical tips for individuals considering psychedelic therapy, highlights the role of mindset and placebo effects, addresses healthcare inequities, and recommends resources and training programs. Tune in for an enlightening conversation on the transformative power of psychedelics with with Andrew Penn, MS, PMHNP.
Get the full digest of insights here!
Andrew Penn: [00:00:00] That's one of the first teachings of psychedelics is like the world is not an either or. It's a both. And so our challenge, I think is going to be to walk that talk. How do we hold a both and model rather than an either or?
Carlene Macmillan: Welcome to the Psychiatry Tomorrow podcast. I'm Dr. Carly McMillan, and in each episode we interview thought leaders in the deep end of Psychiatry's Next Frontier, dive into the latest research, innovative treatments, technology and policy development, shaping the future of psychiatry.
Carlene Macmillan: Join us on this journey to discover what's next in mental healthcare so you can stay ahead
Alison McInnes: of the curve.
Alison McInnes: And I'm your co-host, Dr. Allison McGinnis. Today we have a fascinating and thought-provoking episode for you where we dive into the world of psychedelic assisted psychotherapy and its implications for the future of mental [00:01:00] healthcare. Yeah. So we're
Carlene Macmillan: incredibly excited to have Andrew Penn, a professor in the community health
Alison McInnes: systems at U C S F School of
Carlene Macmillan: Nursing as our special guest today, Andrew's a trained practitioner in psychedelic assisted therapy and a leading
Alison McInnes: expert in the.
Alison McInnes: I really enjoyed my conversation with Andrew. I knew him, uh, previously, um, at a different work setting, and I was impressed by his passion for increasing access to care. He's been such a champion of empowering nurses to help with the provision of psychedelic medicine, for example, as they're already experts in creating a safe psychological setting for patients.
Alison McInnes: We explore the importance of set and setting in the context of psychedelic experiences, focusing on establishing empathy and creating trust.
Carlene Macmillan: Yes, and I really resonated with this concept of glacial change through a psycholytic approach. Um, as Andrew discusses the significance of gradual, incremental transformations rather than seeking one-off monumental break breakthroughs.[00:02:00]
Carlene Macmillan: Literally the intervention itself is the tip of iceberg, but there's so much ongoing work that. Contributes to these courses of treatment. He also discusses how these medicines can be powerful, placebo enhances and the biological
Alison McInnes: signatures of hope. Yeah. Andrew agrees with another of our guests on the show, uh, Dr.
Alison McInnes: Boris Heifetz, in that they both think the placebo effect has been much maligned when rather it is a very useful tool that we can use to enhance patient wellbeing and maybe even keep doses of medicines lower than the otherwise would be. Mm-hmm.
Carlene Macmillan: And I was also intrigued by Andrew's insights on depression as a disease of disconnection and the potential of psychedelics to foster a sense of fundamental connectedness and awe through group therapy.
Carlene Macmillan: I personally love group therapy, love running groups, um, especially, and I really feel that it's underutilized across the board in the mental health field.
Alison McInnes: Yes. Uh, I echo that I, I ran a group oral ketamine therapy clinic at Kaiser Permanente and H M O, and patients felt so connected, they would [00:03:00] open up like flowers once the, uh, ketamine took effect.
Alison McInnes: Um, in the group setting. It was an antidote to their isolation and despair. So we have a lot to cover, and we're thrilled to bring you this rich and engaging conversation. All
Carlene Macmillan: right, so let's dive into our interview with Andrew Penn and explore the intriguing world of psychedelic assisted
Alison McInnes: psychotherapy.
Alison McInnes: I had the great good fortune to meet our guest today when I was, uh, developing ketamine infusion therapy program at Kaiser Permanente in 2015, and I found a kindred spirit in in Andrew Penn. Um, Andrew is a psychiatric nurse practitioner. And has since become an associate professor at the University of California San Francisco.
Alison McInnes: He's also on the steering committee for Psych Congress and has been a tireless champion of nurses and mental health. During the course of his career, Andrew has become well known for his work on the therapeutic use of psychedelics in mental healthcare and the integration of these approaches into mainstream psychiatry.
Alison McInnes: Today we're gonna focus on a particular aspect of psychedelic [00:04:00] medicine, which is the role of mindset and setting. But let's first get to know Andrew in his own words. So Andrew, can you tell us about your career journey and how you became interested in psychedelic medicine?
Andrew Penn: Yeah, thanks Alison. It's, uh, nice to see you here.
Andrew Penn: I'm trying to remember when that was, that you were starting that program back at, at, when we were both at Kaiser, was it? Uh, 2015. 2015? Mm-hmm. Wow. That was like the early days of ketamine and psychedelics at. All of eight years ago now, which is amazing to, to think about how much has happened in such a short period of time.
Andrew Penn: How did I get interest in psychedelics? Um, well, I would say I blame Aldis Huxley because I was, ah, you know, I, I came of age in the eighties, which was, uh, you know, probably the. The lowest point with regards to the, the, the sort of narrative around, around substances that change consciousness. You know, it was sort of the height of Reagan's drug war.
Andrew Penn: Um, the sixties were something that [00:05:00] happened a long time ago, you know, that our parents were somehow involved with maybe, and I read somewhere that the band, the Doors had gotten their name from a book that Aldis Huxley had written about psychedelics. And I'd read Aldis Huxley. In high school, um, brave New World.
Andrew Penn: And, uh, so I, I got the doors of perception out of the public library and read it and I thought, this is really weird and interesting. Um, and it kind of squared with the stories that we'd been told about the sixties, which were a little before my time. Um, You know, and it, but, but a very different way of, of thinking about it and, you know, and I kind of put it aside and didn't really think about it that much, um, until, you know, really probably a dozen years or so ago.
Andrew Penn: And then I remember asking my pharmacology professor when I was a nurse practitioner student at U C S F in the mid 2000, early two thousands said, you know, how does M D M A work? And she [00:06:00] said, I don't know. You should go look it up. So, so I did and, and that sort of got me, I think at that point maybe I'd read about the studies that MAPS was doing with, uh, with M D M A and started following that.
Andrew Penn: And I remember trying to go to the first conference in 2010, but I think it sold out. And so I went to the 2013 conference and, you know, started realizing this was actually an an area of, of serious inquiry and I'd been involved with. Psych Congress for a couple of years at that point, uh, which is a big continuing education conference that happens every year.
Andrew Penn: And I did a talk, I think in 2012 about bath salts. Which was sort of the mor ah, yes. The moral panic of that time. You know, and, and it turns out well, bath salts are substitute catone, which are not that dissimilar from M D M A. In fact, number of the, a number of the, the, what were pejoratively called bath salts, um, [00:07:00] Are actually drugs like meth alone that are under investigation for their potential use as, uh, potential therapies now.
Andrew Penn: And so in that, in that talk, I had to sort of embed my interest in psychedelics in this talk that was ostensibly kind of a drug abuse talk. And, um, as time went on, it. I, I started talking less about drug abuse and more about these as therapeutic agents. And so that's sort of what's got me here. And then in the, in the time in between those two points, say I went through the California Institute for Integral Studies, psychedelic, uh, certificate in psychedelic therapies and research C P T R back in 2017.
Andrew Penn: It was their second class and. Some colleagues from that class and I, who are also nurses, we started an organization called the Organization of Psychedelic and Entheogenic nurses or open nurses to advocate for the role of nursing in the space. And in the last few years, it just sort of feels like it's taken off like wildfire.
Andrew Penn: You know, the, [00:08:00] just the interest, the public interest in psychedelic therapies and ketamine and such and, and the professional interest is all just intersecting in a way that is, it's going so fast that. It's a challenge to keep up with it all. Honestly. You know, it used to be that you could read all the papers and kind of know all the studies that were happening, and now I'm.
Andrew Penn: I'm finding papers that I, you know, didn't even know existed. So it's an interesting time. Yeah,
Alison McInnes: yeah, it is. I mean, just earlier this morning when we were chatting, um, I was thinking about the, uh, Robin Har Har Carhart Harris paper, um, canalization and different forms of, you know, warm and, uh, temperature, I think an tropic pla neuroplasticity.
Alison McInnes: So even just the concept of neuroplasticity is, You know, breaking apart, um, and getting more complicated. Um, you know, I was interested when you said you read, uh, s Huxley, um, was, you know, that that's a commonality with a lot of the folks that I've been talking to about, you know, how they got, they got [00:09:00] started.
Alison McInnes: Um, and what about, uh, Terrence McKenna? Did you touch on the Terrence's work? I really
Andrew Penn: didn't. Um, yeah, Uhhuh, I, I mean, I, I know some of his work. I, I sort of wish the dose, the, the term heroic dose would go away. Um, I know that's the hero's dose. Yeah, the heroic dose. I mean, it, it, it seems to engender a lot of hubris.
Andrew Penn: Um, you know, when people throw that term around and it just, uh, I, I think there'll be a lot of interest. I think I'm very interested in finding out how do we. How do we match these therapies to different kinds of people and different kind of conditions and, and to, to affect different kinds of outcomes?
Andrew Penn: And I, I think just as you know, there are some people that are going to need 10 milligrams of. Prozac to get better. There's other people that are gonna need 80 and it's, the clinician's challenge is try and figure out who needs what and what's safest and what's effective and what's tolerable. And I think the same will be true for [00:10:00] psychedelics is that there's be some.
Andrew Penn: Psychedelics that are some psychedelic medicines and doses that are better matched to some people than others. And, you know, these are early days, so really we're, we're only just starting to figure this out and there's a long way to go. Yeah. I,
Alison McInnes: I, I, I like it that, uh, I like that comment. Um, you know, there's certain kind of bra, uh, of the early days of psychedelic dosage and people did a lot, a lot, a lot to face ev you know, the darkest demons.
Alison McInnes: And, um, I think we're coming to understand that, that that isn't, You know, necessary, nor is it even, um, a particularly good mindset with which to approach, uh, these
Andrew Penn: drugs. Yeah, it's, it's, I mean, I'll just say to that y you know, it's one of the, the places that has kind of gotten lost in all this discourse is, is psycholytic dosing.
Andrew Penn: I mean, I think that's actually more common in the ketamine space where people are working with these low dose, lower doses. You know, not micro doses, but uh, but on the lower end doses of things like sublingual ketamine, um, which allow for the person [00:11:00] to continue to engage in psychotherapy during the effects of the drug and don't blow people outta the water, and they're a little more approachable.
Andrew Penn: And I, I also feel like in addition to this sort of heroic dose, being a bit hubristic, the idea that. Breakthrough is always required in order to get better. I think a lot of therapy is really not about cataclysmic change. It's about glacial change, and it's about glacial small changes that occur over time that are sustained by enduring actions.
Andrew Penn: You know, so if you make changes and you, you learn to tolerate affective states that were previously intolerable, and then you go out and you try them out with other people and you, you, that's part of your integration, you know, that, that really is the kind of changes that I think tend to endure more than somebody having a big epiphany.
Andrew Penn: And then really not knowing what to do with it. Um, and I think Uhhuh, we've sort of overprivileged the big breakthrough and we've, we've really not given enough attention or value [00:12:00] to these smaller changes that can occur from lower doses that are more psycholytic than psychedelic. And I think. That's an area that we could use some more study as well.
Alison McInnes: Yeah. Excellent point. Um, yeah, and I think, uh, so this kind of, kind of just sets us up for it. So the dose really matters for sure, um, with psychedelic therapy and then the, this idea of the mind, the mindset. And as part of our, the focus of our discussion today, maybe you could, uh, define for our listeners, you know, the mindset as it applies to psychedelic therapy.
Andrew Penn: Yeah. Well, you know, this is, this kind of starts to get to the, the question of, you know, people in the early days of me talking about this would say silly things. Like, well, of course they were less depressed. You got them high. You know, to which I would say, well, you know, why did the antidepressant effects of say ketamine last, you know, for two weeks?
Andrew Penn: Because, you know, we both know that ketamine doesn't, doesn't endure in the body for that long. [00:13:00] But really I think to your question, it really speaks to the importance of the care that is delivered and the environment in which that care is is provided. And that the therapist is part of that environment.
Andrew Penn: You know, there is a space that is co-created between the patient and the clinician that is really important around, that will have an important determination on outcome. You know, we get, we get very fixated on the drugs themselves and the effects that they purportedly have, but, But the, the context in which this is done is really important.
Andrew Penn: And first and foremost, people have to feel safe in order for this to go well. And you know, as a nurse, one of my first orders of business is making sure that the environment is safe and that the patient feels safe and cared for because they're. They may be in a state where they're not able to do that for themselves because they're gonna be in a non-ordinary state of consciousness if the dose is high enough and they're going to [00:14:00] not necessarily have full agency over their body, for example.
Andrew Penn: And so they, they need. Somebody there in order for that to go well, they need somebody there who they feel like they can trust to be not only physically vulnerable with, but emotionally vulnerable as well. And know that that whatever comes up is going to be held with, with, uh, kind of a loving kindness and equi poise and, and care.
Andrew Penn: Um, and that's what allows people to settle into the experience and to feel that kind of safety that I think that these. Medications can engender, you know, I mean, I remember, uh, Patient that I sent of mine back in my Kaiser days, who actually went to the phase two M D M A, uh, study of, uh, for P T S D. And she had had a single experience at M D M A earlier in her life, um, when she was younger and first kind of uncovering her trauma, not in a therapeutic setting, but just [00:15:00] recreationally.
Andrew Penn: So I asked her, I said, you know, what was that like for you? And she said, you know, that was the first time I ever felt safe in my life. Um, and I think, you know, that's a really powerful kind of testimony about the effects of that particular medication. But if you're in an environment that doesn't feel safe and you're with people that you don't feel like you can trust, that's a setup for it not to go well.
Andrew Penn: So I think the quality of care and the quality of presence that clinicians bring to this is of utmost importance.
Alison McInnes: Yeah. So, so yes. I guess here we could sort of compare and contrast with maybe doing a psychedelic at Burning Man. And doing a psychedelic with the intent to heal, um, one situation, that set and setting is not controlled.
Alison McInnes: And in the other, there's, you know, very, a lot of careful thought that goes into it. And yet it's the
Andrew Penn: same substance. Right. Right. And that's, and that's the puzzling part, right? Is that same substance, different settings, different outcomes. Yeah.
Alison McInnes: And let's, let's expand a little bit more on this idea of creating safety.
Alison McInnes: And [00:16:00] so there's the relationship with the clinician and let you, were giving the example of say, nursing care. Um, so there's that, there's that relationship that's a component. And what about, um, what about that relationship? Like what creates what, what. Kind of attributes does the clinician need to think about or have or manifest to create that a good, you know, clinical relationship?
Andrew Penn: Yeah, I mean, foundationally, it's based on trust, right? Because if you don't have trust, you don't have a anything. And, and so that trust has to be earned. Um, we don't, and we don't just get to be trusted because we have credentials or, you know, we're working for a fancy hospital or whatever. I mean, those, those help to contribute to that, that experience of trust.
Andrew Penn: And we've had subjects in our studies who've said things like, you know, well, you know, I feel safe with you guys cuz I know U C S F is world class and I trust this hospital. And, you know, so we benefit from that kind of halo effect, but ultimately it's [00:17:00] gonna be about me as a clinician. And so can I, can I be trustworthy?
Andrew Penn: And, and then once I'm trusted, can I be. Invited into that person's inner world because really, you know, I, I've, I've talked about this before, that it's kind of like we're remodeling the interiority of their house. You know, the outside of the house is gonna stay the same, but the inside is gonna be remodeled.
Andrew Penn: And I'm like the contractor and designer, and they are the client, and I'm, I'm not coming in, you know, so the first thing I need to do is pay attention to how they live in their house now and what they want it to look like when it's done. How they're gonna live in it when they're done. And, and that's part of what we do in preparation is, is really getting to know the interiority of that person and of that, that, that.
Andrew Penn: That house that they live in inside their own, their own being. And then, but I have to be invited into that space. I don't just march in and say, well, I'm gonna tear out a wall here. You know? [00:18:00] Um, I, I want to know. And also in preparation, I also wanna know what I might find behind the walls, you know? So that's partially why we're having this period of non-drug treatment.
Andrew Penn: Where we're getting to know each other. I mean, the patient is getting to know me, I'm getting to know them, and we're learning about each other. We're both learning and teaching. They're teaching me about them. I'm teaching them about what they might expect and how they can best use this experience. And we're both, we're both learning from each other.
Andrew Penn: And in that learning process, we're creating a a solid container and. And I can start to see the world through their eyes and maybe they can potentially start to see the world in a different way, a different possible way. Um, and so that, and then, you know, when we get into the difficult stuff, we deepen that trust by being, having impeccable integrity, you know, always acting with integrity.
Andrew Penn: Um, we, we get there by not flinching [00:19:00] when difficult things come up. You know that we can be present for whatever comes up and we can hold that with a kind of loving kindness that's safe, um, and supportive. And that deepens the trust. And so, you know, this is especially important when maybe there's gonna be a repetition of this cycle.
Andrew Penn: You know, we're going to do some non-drug integration afterwards. And then maybe, like in the case of ketamine, we're gonna do this again in a month. So, you know, each time we go through this cycle, We have the opportunity to deepen that relationship and that trust and that's going to allow that patient to go into the more difficult stuff, the more scary stuff that, you know, one of the things that's been talked about with psychedelics as opposed to conventional, say antidepressants and, you know, there's a, there's sort of a sport in the psychedelic space of making strawman arguments about conventional psychiatry and antidepressants and I don't really have a lot of patience for it cuz, you know, there's a lot of people that benefit from those medications too.
Andrew Penn: And we're gonna continue to need those, even when [00:20:00] we use psychedelics. So we don't need to make strawman arguments about antidepressants. But, you know, one of the downside standard depressants is that they, they do tend to dampen depressive symptoms. They also d tend to dampen other emotional experiences too.
Andrew Penn: And so, you know, people will say, well, I don't feel depressed, but I don't feel much of anything. And so in a way they kind of contribute to experiential avoidance, which is that like, I don't wanna look at these difficult things. So this kind of turns down the volume on them. And sometimes, you know, that is a real blessing and I don't wanna, I don't wanna disparage that.
Andrew Penn: The downside is that you also don't feel the other good. They don't feel good things as well. Like people talk about like, you know, I don't. Feel joy either. I don't, I used to cry in movies. I don't cry in movies, sad movies anymore. Um, whereas psychedelics, including ketamine, I think to some extent tend to do the opposite.
Andrew Penn: They say like, Hey, you're not getting away from looking at this difficult stuff, you know? And the further you try and get away from it, like the more it's gonna kind of [00:21:00] come after you and you know, maybe that's what you call a. Difficult experience or a bad trip. Um, but they do have this proclivity for saying like, we're gonna look at that difficult stuff today.
Andrew Penn: And you have to prepare people for that, you know, and you have to say like, Hey, you know, that difficult stuff may come up and I'm here for you, and we've put all this time in, in the days leading up to this to make sure you feel safe so that you can. You can get into that stuff if you want to go there, you know?
Andrew Penn: But ultimately, it's always the patient that chooses how deep they want to go. The therapist should never be trying to push through people's resistance. Like that's how, that's how you do harm. So, you know, sometimes people are resisting for really good reasons, and we need to respect that, and we shouldn't be trying to knock those walls down in the middle of a session that's inappropriate.
Andrew Penn: And I think that's where harm gets done. So it's about. It's about knowing how far you can go and when. When you've gone too far, how to pull back [00:22:00] from that? Uh, it's a, that's why it's a really subtle art.
Alison McInnes: Yeah. It's a really graceful dance. Um, uh, how so, so how can we think about, um, the best way, cuz this is so complex already.
Alison McInnes: Um, how do, how do we prepare patients specifically for this? What, what do you
Andrew Penn: do? So in our studies for a psych. Yeah, so, you know, I'm working on studies of psilocybin for, you know, various aspects of depression. You know, like people with depression that have Parkinson's disease as well, or people that have bipolar two disorder, which often comes with a lot of depression.
Andrew Penn: And so, you know, we've, we've looked at this quite a bit in our, in our studies and. You know, a lot of what we're doing to prepare is really relational. You know, we're, we're making sure they know us and they feel comfortable with us, and that we've, we've really tried to answer all of their questions and that we've anticipated where there [00:23:00] might be some challenges that come up.
Andrew Penn: Um, and of course we make the physical environment really comfortable too. You know, we have a little. You know, kind of living room and like environment that is very private and quiet and you know, you're not gonna hear people banging around in the next room and nobody's gonna come barging in. And, you know, we really want that space to feel very safe.
Andrew Penn: And also not clinical. You know, we don't, we don't have, um, medical equipment lying around and stuff like that. It doesn't look like a hospital room.
Alison McInnes: Something that I, um, that I kind of struggled with was how, you know, in terms of establishing the mindset to, to, to receiving the treatment. Um, w which is to, you wanna encourage someone to be hopeful, but also you have to acknowledge that maybe the treatment won't work.
Alison McInnes: I mean, it's a complicated it really complicated message.
Andrew Penn: Yeah. And we're up against a lot of, A lot of stuff in the media and in the culture at large right now. Um, [00:24:00] like it's, it's, you know, very fashionable to be disparaging of antidepressants. And so I think, you know, people, if they're starting antidepressants often have very low expectations of them, whereas the opposite is true for ketamine and psychedelics.
Andrew Penn: Like these are, you know, because of. You know, Michael poll's work and you know, stuff on the major media outlets. You know, there is this sort of miracle cure, uh, narrative that's out there. And, and I think it's, uh, you know, it's, it's certainly created some challenges. You know, we call it the pollen effect, uh, sometimes, because, you know, when we ask our subjects like, where'd you hear about this?
Andrew Penn: Almost invariably they say, well, I read Michael Poll's book, or I saw the Netflix special or something. And I appreciate that and I think Michael's a great storyteller. It's, it's just the challenge that we're facing right now is, is creating some, some mod, some more moderate expectations. And, and part of those expectations as I'm starting to develop this thought is, is that y you know, in psychiatry we, [00:25:00] we had this.
Andrew Penn: I, I always say in psychiatry we have antibiotic envy, like, you know, like this Freudian antibiotic envy. We, we want our meds to work as well as say, you know, azithromycin does for a, an infection. And, and I get that because, you know, our, our medications are kind of modestly effective a lot of the time. I mean, there are some that are really quite impressive, you know, and, and how well they work when they work, but, We don't have that kind of same speed of, of effect and the duration of effect that we see with some other diseases, disease states.
Andrew Penn: Um, and so I think we've kind of engaged in this fantasy and biological psychiatry that we can just sort of knock a disease out. Like you might knock out an infection. You know, we even call some of our drugs tic, you know, which if you're not, you know, if your background isn't in biology, you know, and a lysis lysing a cell is to sort of poke a hole in it and let the.
Andrew Penn: The guts leak out and it kills the bacteria. You know, that's how you kill a bacteria is you lice it. [00:26:00] Um, and you know, as if we could do that with like anxiolytic medications, um, and the reality is, I think is different. I think the reality, and I think this is what's happening with psychedelics, is that people are changing the relationship they have to their illness, and so mm-hmm.
Andrew Penn: You know? Mm-hmm. When I think about that, when I think about that, Patient of mine who went through the M D M A study, you know, she had really bad P T S D from childhood abuse and at the end of it she still had P T S D. But this is the part that's weird. It was different. It was, it had a, her relationship to her illness and her relationship to her trauma had fundamentally changed and it became like, This is something that happened to me versus like, this is what controls my life.
Andrew Penn: And, you know, did it eliminate her memories of her trauma? No, of course not. Um, but she had a different [00:27:00] relationship with them, you know, and I think that's the part, so, you know, how does that apply to depression? Like, you know, does somebody. Change their relationship to depression where rather than trying to cut this thing out of them, you know, I mean, we, we learned that from Jung, you know, that you don't become whole by cutting some part of yourself off.
Andrew Penn: You know, you integrate all these parts of yourself into the hole. And so I. Do, do we change the relationship somebody has with their depression, with a psychedelic or with something like ketamine? I don't know. You know, I think this sort of phenomenology is something that was, is really worth trying to understand better.
Andrew Penn: Because what I see in, in these studies is not that people come in and they're like, oh my God, it's gone. You know? They'll say, yeah, it's still there, but I just have a different relationship with it than I used to. Yes, and that's, and I think that's worth. Trying to understand better because if we can explain that to patients that it's, it may be about changing the relationship and not about just [00:28:00] cutting this depression out of you like it's a kind of tumor, you know, then maybe that's a more realistic expectation and maybe helps guide the work in a different way.
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Alison McInnes: Yeah, I, I remember that so vivid vividly from, you know, all the ketamine patients that I've talked to, and they would repeatedly say that they just had a new perspective and mm-hmm.
Alison McInnes: That everything was the same, all the difficulties in their life, [00:29:00] same. But that somehow or other, it, it, you know, they, they felt that they could, they had some emotional resilience, I would say probably. I felt like resilience is really an important
Andrew Penn: role player. And a feeling of connection. I mean, you know, one of the things that Ros Watts has, has done such a nice job about is really talking about, you know, for people that don't know, Roz is a psychologist in the UK who's done some really beautiful work around psychedelic integration and really talks about how depression is a phenomenon of disconnection.
Andrew Penn: You know, you feel disconnected from other people. You feel disconnected from pleasure, you feel disconnected from yourself. Um, and that psychedelic experiences, and maybe this is through the phenomenon and of awe, where we realize, like this little storyteller that tells, really tells us, we tell ourselves really terrible stories about ourselves and about the world we live in, you know, is just one perspective and that there are other perspectives and that, you know, I, this is [00:30:00] easily misinterpreted that, you know, people with depression don't want to have this internal narrative that they are, um, mis that they're unhappy and that everyone hates them, and that they'll never feel better.
Andrew Penn: I mean, that, that they're not, it, it's, you know, I've heard it call, I've heard depression go pathological introspection. You know, you, you don't really wanna be thinking about yourself all the time, but you can't stop yourself from having all these negative thoughts. And maybe there's something about that.
Andrew Penn: Experience of awe that is often part of a psychedelic experience where you realize like, oh my gosh, I'm just one story in a sea of billions of stories. What a relief. You know? And, and there's so much wonderful stuff out here to connect with, like, you know, the beauty of this tree or, you know, my, my partners smile, or you know, any one of the numbers, you know, cuz it's not.
Andrew Penn: I don't think it's about seeing, I mean, some people see God, that's great. [00:31:00] Um, other people just see what's always been right in front of them the whole time, and they have, and suddenly it's like, you know, it's like the, uh, William Blake said, you know, the doors of perception were cleaned and we could see the world as it is infinite.
Andrew Penn: You know, that, that it's not, it's not limited by the constraints of our own mind, which is so often our worst enemy. Especially when we have depression. Yeah.
Alison McInnes: I really re Yeah, I can really relate to that. I've had the, you know, the experience of the fundamental connectedness of all things. Yeah. Which, um, from live when I was living in a monastery and mm-hmm.
Alison McInnes: You know, so there. There are ways to get this that are not unique to psychedelics, right? But they speak to a, you know, a, a wonderful healing state. Um, uh, okay, so, uh, let's think about, um, again, if we could maybe address, um, thinking about. Mindset and why it's so, uh, important in psychedelic assisted therapy.[00:32:00]
Alison McInnes: Um, cuz it's mindset's important to everything in life, right? I mean, sports psychology and, and other things. Um, so why is it so critical in the case of the psychedelic the, well,
Andrew Penn: you know, there's this interesting idea in psychedelics, um, I think it was Ito Har Harkins who, who talked about this, said that, um, you know, psychedelics are placebo enhancers.
Andrew Penn: And when I first heard that, I kinda scratched my head and said, wow, what does you mean by that? And you know, the word placebo has a, has a really bad rap, right? Because we think of placebo means like, oh, you got fooled, right? And the reality is, is that the placebo effect is present in every clinical treatment.
Andrew Penn: We may not be giving a placebo, but there's always an element of placebo in every treatment, even if it's an active treatment. And I think that the emphasis on mindset and set and setting is, uh, is an element of that. And so let's, if, if people haven't totally shut down, After hearing the word placebo, I mean, let's check this [00:33:00] out.
Andrew Penn: So, you know, what are the elements of the placebo effect? I mean, the, the, the, the, they, I mean, there's wild things about the placebo effect. You know, you can, you can reverse placebo anesthesia with Naloxone, which is the opiate reversal drug. Right? So not even giving an opiate, but just people believing that they've gotten benefit.
Andrew Penn: From a, they don't know it's a placebo, but they're reporting analgesic effects from a placebo. If you give them naloxone without them knowing it, they'll tell you that pain responses, that pain, uh, relief has worn off, has gone away. So there's this biological underpinning to placebo effects, but there's also these sort of human aspects of like, there's something really empowering about deciding I'm going to do something to make my life better.
Andrew Penn: You know, so, When somebody walks into my office and says, I'd really like to get help with my depression. We might think of that as day one, but they've been thinking [00:34:00] about getting help for maybe weeks or months or even years, and finally deciding, okay, this is it. I'm gonna do something about it. And they didn't cancel the appointment and they did show up and they came in.
Andrew Penn: And so that action precedes improvement. And, and just the very act of taking that first step, um, will have benefits. And I think the same is true for psychedelic therapies. And I think this is a big part of what Microdosing is probably about. It's about people taking agency over their own wellbeing and whether or not how much the drug has an effect.
Andrew Penn: It's a difficult thing to parse out because in clinical trials, Nobody's surprised that blinding is rather difficult in these studies, so people tend to know if they got active drug. And so doing the typical ways that we parse out the difference between an act, the effects of an active drug versus a placebo are kind of confounded by the fact that people tend to know that they got a placebo in a clinical trial was easing a [00:35:00] psychedelic.
Andrew Penn: But I don't think that really matters. I think. Any, you know, so, so setting out to get help for yourself, um, having a clinician respectfully listen to you and understand your story and tell you, there are things that we can do. There is, there's, we can help you with this. And then, um, you know, and all the symbols of, of treatment, you know, all the, those, why do, why do people wear white coats in hospitals?
Andrew Penn: You know, it's a signal that you're in a place that can help you. You know, like, why do we put our. Why do we put our, our diplomas up in our offices? It, it engenders confidence, you know, so it, it builds into this ritual of, of care, which all of these things go into the mindset. And then you have this, you know, the, you have these compounds, ketamine, psilocybin, M D M A, whatever that, that engender these very powerful experiences and so, Those can be amplified by those attempts to, to take care of [00:36:00] the, the setting and, and they tend to, as Stan Groff said, they're nonspecific amplifiers.
Andrew Penn: So, you know, whatever you kind of go into that session thinking about, you're probably going to think more about it. You know, your thoughts may take a total left turn and you end up thinking about something else, which is another reason why I think it's valuable to tell patients and participants in these, these treatments to hold those intentions loosely, you know, lovingly and loose and loosely, um, because something else may need to come up and we entrust that.
Andrew Penn: There's a kind of wisdom to that. Process that, you know, nobody can really fully explain cuz it's sort of beyond our way of knowing, you know, sort of rationally. But say, you know, whatever comes up is probably what needs to come up. Um, and even if it's scary and difficult, that's okay. We're gonna work through it.
Andrew Penn: And that's part of why that setting the stage is so important. Because if [00:37:00] something difficult comes up, we really want to have that foundation of trust and care. That's going to allow that person to know that they're gonna be okay.
Alison McInnes: Yeah, I've, I've. You know, people have often spoken about this idea that if you can make meaning out of the difficult experience, it can still be really healing.
Alison McInnes: Oh yeah, absolutely. Yeah. You know, and yeah, and the soul not wanting to use the term bad trip. Well, we all know what a bad trip is, but, um, so let's, let's think for a second about, uh, you know, sort of the patient oriented aspect of things. Um, so for individuals who might be considering this, You know, psychedelic assisted psychotherapy.
Alison McInnes: What do you, what do you think are some important factors they should consider before embarking on the journey and maybe in choosing a care provider?
Andrew Penn: Yeah. Well, I, you know, I think on, uh, on some level you've gotta feel safe. You know, you've got to be able to mm-hmm. To relax into the experience. And, you know, for a lot of [00:38:00] people, this is much more of a.
Andrew Penn: It's a somatic experience of trust. You know, their gut will tell them, this feels good, this feels safe. Um, you know, it, it's always gonna be a bit of a leap. So, you know, you're probably never gonna feel a hundred percent at ease. And that's okay. You know, but you have to feel willing to, to, to, to take that leap with this person that's treating you.
Andrew Penn: I think that's, that's really gonna be important. Um, You know, just so that you're, and that's, and that's understandably very difficult for a lot of patients, you know, especially if they've had trauma, you know, if they've had issues around trust. Um, that's a big ask. And that means that we have to be very trauma informed in our care and be transparent about that.
Andrew Penn: You know, I think part of what we do in therapy is we make the un, we make the unspoken spoken. You know, we have to, I think as [00:39:00] clinicians, we have to engender a kind of courage that allows for patients to have difficult conversations with us. And we model how do we, how do we do that as clinicians? How do we be courageous so that that patients feel safe with us?
Andrew Penn: And because if they don't feel safe, they're gonna struggle. To really enter that experience fully. They're always gonna kind of keep one foot outside the door in case they need to get out of there. And, and so you know this, yeah. This might require kind of easing, easing into the experience. You know, maybe you don't do a high dose of ketamine for your first journey.
Andrew Penn: You know, you, you have a little, you have a little handshake with the medicine. You know, you're not, you don't go in for a full hug here, you know, we just have a little taste of it and see what, what's, that's, you know, what, what's the signature of this medicine? What does it feel like in my body? What does it feel like in my.[00:40:00]
Andrew Penn: Emotionally, you know, and then be patient. You know, this, this, there's so much impatience in the field right now, and we all wanna, you know, we all wanna do this for everyone right now. And I, I, I just feel like there's, there's a lot of things we still don't know about this work. And, you know, it's always gonna be an evolving body of knowledge.
Andrew Penn: We won't know everything before we. Kinda let this out into the public, but I, I think that kind of impatience doesn't serve us, and I don't think that's, and I don't think the impatience. Is really, you know, impatience is not one of the teachings of most of these medicines. You know, if anything, they engender a kind of like timeless spaciousness where, you know, it's like, that was an hour, that felt like a month, you know, that I was in that space.
Andrew Penn: And maybe it's trying to tell us something of like, you know, take your time, don't rush. Look around, you know, uh, I don't know. Um, but I, I, I do [00:41:00] sometimes feel like the haste that we're getting into in this space may ultimately inadvertently cause some harm. I don't wanna avoid that.
Alison McInnes: Yeah. I think, um, Over promise is something I worry about as well.
Alison McInnes: Yeah. Because I know that I, you know, I think it's really important, like for me, I would feel good about a provider who says, you know, you, you don't wanna convey the, convey the impression that this is the only treatment that's gonna work. Like this is the big bang. Yeah. You have to be prepared that there are alternatives and that there's, you know, nothing wrong with a patient if they don't, if the medicine doesn't serve them.
Alison McInnes: Um, and I think. That's a bit of a problem, um, currently as well. Yeah.
Andrew Penn: Expectation. Expectation management. Yeah.
Alison McInnes: Expectation management. A a hundred percent. Um, I want to, to bring up the subject of healthcare inequities. So the magnifiers. So, um, we've been talking about magnifiers and I feel like, uh, healthcare inequities, so get magnified with psychedelics as well.
Alison McInnes: Um, you know, you have ketamines out of [00:42:00] pocket largely. Yeah. And you need to have it near you and it's not paid for, you know. By insurance largely. And, um, the, there was an example of a, of a, of a provider of psilocybin in Oregon. So there's, you know, there's this kind of tension between like corporate psilocybin and like sort of the hand grown psilocybin in Oregon.
Alison McInnes: But you know, this provider went to all this trouble, you know, to set up a clinic and they grew their own mushrooms. And the mushrooms are inexpensive. True, but the treatment is a thousand dollars and you need at least two. And, you know, so there you go. I mean, you know, Bobby, we were talking about this a bit earlier, but, um, it's, it's unfortunate that there's this tension between the two camps.
Andrew Penn: Yeah. You know, the, and I think we're gonna see more of that. I mean, we certainly saw it in the ketamine space where, you know, the drug itself is, is a few bucks, but the, the, you know, each infusion is often, you know, many hundreds of dollars because of the personnel costs involved in the overhead of running a [00:43:00] clinic.
Andrew Penn: Um, you know, as. As unpopular as this may be, because there are some, there are some factions within the psychedelic space that really believe that this should never be, um, made into a pharmaceutical medicine. This should never be paid for. And you know, as, and as, as much as I admire the ideals that these people bring to it, I, I feel like it's, it's, first of all, it's not real, very realistic.
Andrew Penn: And second of all, it's. It's also in, it doesn't square with equity because, you know, unless these people that are kind of assailing the cost of this are willing to work for free, which most of us, you know, frankly can't afford to do, um, they, they're gonna need to be compensated for their time. And honestly, one of the, one of the great things that we could do for improving equity in this space is to have.
Andrew Penn: Treatments that are [00:44:00] FDA approved so that they can be covered under Medicare, so that our lease privileged Medicare and Medicaid, so which are safety net insurance c plans in this country, you know, federally, um, paid for. Health plans so that those folks can have access to it as well. Because if we just, if the only people that can have access to this are people that can fork out a thousand dollars a, a journey, and I honestly, I think that'll be on the lower end of cost, um, you know, to do that in Oregon.
Andrew Penn: Well, that's great for those people who can afford to do that, but there's a lot of people who don't have those kind of resources, but they might have Medicare. And if we really are serious about. Addressing some of these equity issues, we really need to think about how people are gonna pay for this. And one of the ways we've traditionally done that is by having this as a FDA approved medication that is available [00:45:00] under Medicare insurance.
Andrew Penn: And you know, that that's gonna be really important for, for making this available.
Alison McInnes: Yeah, a hundred percent. Um, agree. Uh, so, um, what, what practical tips, uh, you do a lot of education at at psych as a part of Psych Congress? What practical tips can you offer to mental health professionals who want to incorporate psychedelic assisted therapy?
Alison McInnes: I mean, in terms of like, are there programs or things that you read? Um, training courses, that type of thing.
Andrew Penn: Yeah, so, you know, there, there appears to. Kind of feels like mushrooms after the rain. You know, every time I turn around there are more training programs that are offering certification in psychedelic therapies.
Andrew Penn: And I think they're all, you know, a noble effort, um, in trying to address sort of the provider gap, which is likely to occur. Um, they, they have. Challenges in that those curriculums are not standardized at this point. So really it's [00:46:00] up to the person who's creating the program to put whatever they want on the curriculum.
Andrew Penn: Which, you know, as we know from other more traditional training paths is not the case. Like, you know, if you go to nursing school in this country, if you've gone to an accredited program, Um, there's gonna be standard elements in that curriculum that all those schools will have, as, you know, they have to have as part of their accreditation.
Andrew Penn: No such thing exists in the psychedelic space yet. Um, there isn't even really, uh, agreement necessarily as to what, um, what constitutes a psychedelic assisted therapist, right? So these are, these are challenges. And then we also have to look at how long it takes for people to be, to move into these, into these roles.
Andrew Penn: So, you know, to train a. Therapist in the us you know, post-college is anywhere between sort of three to seven or eight years. That's a long period of time. And so, you know, one of the things that I've been advocating for as a nurse and looking at the role of nursing in this is that, you know, we have 4 [00:47:00] million nurses in the United States, many of whom would probably like to quit their jobs.
Andrew Penn: Because if you look at the reports of burnout and and such, um, a lot of people. Wanna get out of their job they're in. But, and some of 'em talk about leaving nursing, but I think they really would like to stay in a role where they're taking care of patients. They don't necessarily wanna work in a hospital.
Andrew Penn: Um, and I see a real opportunity there in those, if you were to take even just 1% of those 4 million nurses, that's 40,000. Potential clinicians who are already licensed, who are already knowledgeable in things like patient care and pharmacology and managing emergencies, if they should arise and you give them some additional training, you know, just like, I mean, I haven't been a hospital nurse for 18 years, and so if I was gonna go back and work in a hospital, I would need some retraining, but I could pick it up pretty quickly I think.
Andrew Penn: And so, I think for nurses who are really interested in, in pursuing this work, there's a really, uh, this could be a real win-win because we keep those, we [00:48:00] keep those clinicians, uh, enrolled as nurses. We don't lose them to other professions, and we begin to really populate the psychedelic assisted therapy.
Andrew Penn: Therapist ranks with clinicians who are skilled at dealing with patients in sort of many different states of consciousness, know how to administer medications, um, and really pr as part of their, their natural intelligence, native intelligence, rather, really know how to sit and be present with patients in a way that.
Andrew Penn: That delivers care, um, and allows for this sort of natural unfolding of these states that happen in psychedelic therapy to occur without excessive intervention and without, um, rushing in to have to do something. You know, we often say in these trainings, uh, don't just do something, sit there, you know, and watch it.
Andrew Penn: Unfold Because often what happens is I've seen in, in our subjects, in our study is that, you know, they may be having a very intense emotional experience [00:49:00] one minute, and then a minute later it's shifted into something else and. We didn't have to do anything to make that happen. We just had to be present and allow that unfolding process to happen.
Andrew Penn: And it's difficult for those of us who've been trained to intervene. You know, we think, oh my gosh, I gotta do something right? Maybe we don't. You know, maybe the person has some innate wisdom about what they need to do, and the medicine helps them to access that. And our job is to facilitate that access, but not to show them where to go, that they'll figure that out if they're given the space to do that in.
Andrew Penn: And I think, I think nurses would be particularly skilled at doing that.
Alison McInnes: That sounds like an incredible solution.
Andrew Penn: This should be adopted. It's, it's one, it's one of, it's one solution. We're gonna need a lot of solutions to figure out how to, how actually operationalize
Alison McInnes: this. Yeah. Scale. I, cause I'm a big fan of group dosing and so, um, I think that there's a role for that as well.
Alison McInnes: Yeah.
Andrew Penn: You were an early adopt. Yeah. [00:50:00] As an early adopter. I remember when I came to visit you at, at, at, at Kaiser, you know, one morning and you had what, a dozen people? 7 38, a few minutes of each other, and. Yeah. And they got, you know, themselves checked in and they had their oral, you know, these were people on what maintenance they'd already responded
Alison McInnes: to?
Alison McInnes: No, we were starting new cuz we didn't have enough room in the, the IV program.
Andrew Penn: Yeah. Oh, right. And, and yeah. And, and, and, and you know, you. This is the other thing too, is that, you know, that disconnection model, we're, we're disconnected from other people. Yes, yes. And you know, we think about healing in these little siloed slots and, you know, maybe we need to not be so vertical but more horizontal and start connecting with other people and the world around us.
Andrew Penn: And, and maybe that's part of the antidepressant. Effects is, is, is, is being able to branch out and connect with other people, [00:51:00] and that perhaps, you know, there's an opportunity there to connect with other people who are going through a similar experience. I mean, that's what, um, you know, Brian Anderson found with his, um, Group, um, psilocybin study of, of, uh, men who were experiencing demoralization from, um, long-term h i v diagnoses was that those guys connected with each other in ways that were personally meaningful to them and.
Andrew Penn: It was a big part of what helped them feel better.
Alison McInnes: Absolutely. I just cheers to Brian, um, for that study. So yeah. So what do you think, do you have, um, some other, any other thoughts for us? Things that we didn't touch
Andrew Penn: on? I think we've covered a lot. Um. I understand the impatience that people have with sort of getting this out into the world, you know, and I see, I see a lot of interest in sort of bypassing the whole medical model and, and, you know, and, and, and I don't think these, [00:52:00] I don't think these models need to be in opposition with each other.
Andrew Penn: I mean, regulators might, regulatory bodies may disagree with me, but, you know, I, I think that we can have. A world in which, yeah, you can go to Oregon and have a personal exploration, psilocybin experience with somebody who's skilled at holding that space. And you don't need to have a psychiatric diagnosis to qualify for that.
Andrew Penn: And we also need to have a place where, you know, somebody's grandmother who's never had, you know, anything stronger than, you know, a a a 2% beer. Um, To experience a non-ordinary state of consciousness to help her depression that maybe is delivered in a more medicalized setting that she feels like she can trust and be able to release and let go and go into do the work.
Andrew Penn: You know? And so I don't think these things need to be an opposition. We with each other, and I feel like there's a lot of sort of narrative that. Tries to do that and [00:53:00] I, I, to which I, you know, I challenge the psychedelic community, you know, like, look, y'all know how to, you know, y'all know how to operate.
Andrew Penn: With paradox and, and seeming contradictions. Like that's one of the first teachings of psychedelics is like the world is not an either or, it's a both. And so our challenge, I think is going to be to walk that talk. You know, how do we do that? How do we hold a both and model rather than an either or, because you know, having everything be in opposition to each other and either or has really.
Andrew Penn: I don't know if it's served us so well as a, as a society, as a culture, as a species, you know, on this planet. And so, you know, if there really is this psychedelic ren renaissance that's happening and I, I look forward to the psychedelic enlightenment personally, you know, the Renaissance has been great.
Andrew Penn: Sometimes it feels like a little bit of a psychedelic adolescence. I'm kind of looking forward to. Moving on to the next stage. You know it, I mean, it just feels [00:54:00] like, you know, I mean, when you're an adolescent, you have very strong opinions about everything, right? And you're sort of offended at the powers that be because they, you quickly see that their words don't always align with their actions.
Andrew Penn: And you call everyone a hypocrite. I. But the, you know, at somewhere around your mid twenties you start, you stop using the word hypocrites so much because you realize you've kind of become one. You know, and, and it's not necessarily a bad thing, it's just you re, you realize the world is a lot more complicated than you thought it was.
Andrew Penn: And that's okay. That's a normal development. And I kind of feel like that's what we're struggling with in the psychedelic space right now is we're having kind of a psychedelic adolescence and we want there to be good guys and bad guys and you know, these sort of grand battles between them. And I think.
Andrew Penn: The reality is probably more nuanced than that and, and I imagine it's probably more complicated than we can actually even imagine at this point in time. And I really look forward to seeing what it looks like, you know, 10 years from now, cuz I think it's gonna be quite different than it is right now.
Alison McInnes: Fabulous. Um, can [00:55:00] you give me again your quote about psychedelics or life jackets against despair, or what was that exactly?
Andrew Penn: Oh, not, not psychedelics, but you know, part of what a placebo effect is, is that it is, it is the biologic signature of hope. You know, so it, when you distill what goes into a, into a placebo effect, there's many different components to it.
Andrew Penn: But at the end of the day, they all kind of come down to an experience of hope and a belief that things actually can get better. And I think we ignore that part of our treatment really to our own detriment. Cuz I think that really has. A powerful ability to help people. And we don't wanna overstate it.
Andrew Penn: You know, we, we, we wanna be, we wanna be moderate in what we promise. We don't wanna, we don't wanna find ourselves like we historically have been over and over again in psychiatry, where we overpromise and we [00:56:00] underdeliver. I mean, that has happened so many times in the history of our profession. I don't want that to happen here.
Andrew Penn: I'd like us to find a way that we can do this. Right. Um, and find the people for whom it really works and help them with it and figure out for whom it doesn't work. I think that's equally valuable and nobody talks about that. You know, we want, we want this to be a panacea, and that's a fool's errand. You know, nothing is a panacea.
Andrew Penn: And so part of what we need to figure out is for whom does this not work? I mean, think about like, think about in like cancer treatment. You know, we now have biomarkers on tumors that tell us this whole class of meds won't work on this tumor. Don't bother because you're just wasting your time and that tumor's just gonna grow while you're futzing around with this med.
Andrew Penn: That doesn't work. You know, we don't have the equivalent thing in psychiatry. We don't have a predictive biomarker for most conditions, and so we need to figure out who psychedelics work for. But [00:57:00] equally we need to figure out who they don't work for so we don't waste their time and energy pursuing a treatment that isn't, is gonna be ineffective.
Andrew Penn: Right.
Alison McInnes: And make them feel that, you know, they've failed something else. Yeah. Medicine didn't serve them.
Andrew Penn: It's more, oh, it's the worst thing we say when we say somebody failed a treatment. You know? Exactly. No, the treatment failed them. Right.
Alison McInnes: Good. We're on the same side there. Okay. Well, Andrew, thank you so incredibly much for spending, uh, time with us today.
Alison McInnes: Uh, that was really illuminating and I look forward to more chats.
Carlene Macmillan: That's it for today's episode of The Psychiatry Tomorrow podcast. We hope you found our discussion informative and inspiring. If you enjoyed the show, why not share it with one mental health clinician in your network? Your support means the world to us and helps us reach a wider audience.
Carlene Macmillan: And if you're enjoying the podcast, we really appreciate it. If you could leave us a rating and review on your favorite podcast platform. It only takes a moment and your feedback helps us to improve the show and reach even more listeners who are passionate [00:58:00] about mental health. Thanks for listening, and we'll see you in the future.