Psychiatry & Psychotherapy Podcast - Partial and Intensive Outpatient Program for Psychosomatic and Medical Illness

Episode Date: April 12, 2023

Over the last several years, Dr. Puder has worked as the medical director for Loma Linda University Health's MEND program, a hospital-based intensive outpatient program (IOP) and partial program that works with patients who have chronic illness and their families. Jesse has been a lead therapist instrumental to the program's success and Brian Distelberg oversees the MEND program and acts as the Director of Research for the program. During this episode, they come together to discuss the MEND program.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Dr. Pudor, Dr. Distelberg, and Jesse Allen have no conflicts of interest to report. All right, welcome back to the podcast. I am joined today with, I would like to say, my boss, one of my bosses. I have many bosses. All of you as listeners are my bosses, I guess. But Brian Distelberg, he is a PhD marriage and family therapist. And he runs the MEND program in Loma Linda, California. He's the, the, head of the department, both the child and adolescent and adult. And he is in charge of all the research and teaches at the university. So Brian, welcome to the podcast. Thanks for having me. And we're also joined with Jesse Allen, one of my favorite therapists in the world. And Jesse is trained in the men model. She's been working with me for

for many years. And MEND is an IOP partial program, which means five to three days a week, seven to three hours a day, depending on if they're partial, partial is more intensive, then we graduate them to IOP. And people who get referred here have medical and psychiatric issues. It's an insurance-based program, and we accept most insurance. I would say, pretty much all of them at this point, which we've had to fight tooth and nail to be able to do. And so today I was hoping to have a conversation around the research that we've published on the MENT program and a practical sort of understanding of things we've

learned about treating people with medical issues. We'll talk about, you know, what is congruence, why we do family therapy. We do family therapy. uniquely, pretty much every day the last hour, right, is multifamily therapy. So family members come in. We'll talk about illness identity and how we help people shift out of an illness identity. How do, how medical issues can be worsened by chronic stress, how through therapy and through the IOP partial program, people's physical issues improve dramatically and how we show that on measures as improving dramatically. So good to have you guys.

Great to be here. Yeah. So we were talking through before we started here, kind of where we started, I came on, when mend adult was launched, I came on. And you had been doing this for a while before with the child and adolescent group. And for those of you who don't know, I spend about five to ten hours a week. And I've been doing that for almost a decade in this program. And so it's not my full-time job, but it's something that I'm a part of, which I'm proud to be a part of, because it's fun to see people get better.

So Brian, why don't we start with you? Describe the Mend program a little bit about it and what schools of therapy it pulls from. and we'll go from there. Sure, sure. That's a big area. We could spend like probably three hours just picking that one apart. It's a pretty complex model, but it does rely on some things that I think are known in behavioral health. And what we did was just kind of take those components and put them together in what I would say, a pretty innovative and effective way.

So there's the men theory and then there's the men program. So the men theory itself is it's a combination of multiple. theories, one of which in kind of the starting foundational theory is an ecologically based theory. Specifically, we were drawing from research and work from University of Rochester, and it's a theory called the Biobehavioral Family Model, which there again is a theory that's an integration of multiple theories. It's basically a theory of ecology, a little bit of human ecology, and then some of the Ingalls work in biopsychosocial kind of ideas of ecological systems. So that was a starting point.

That brought us the understanding of like larger community macro stuff all the way down to the mezzo-relational components. That's ecology. What they added to it was this idea of biobehavioral activity, which then brings us to internal states of the body. So prior to their work, there wasn't really a great understanding in a lot of the fields of behavioral health of how the external world and external relationships impact the actual internal biology of the body.

So that was one of the starting points. That's what we call a conceptual model that helps us understand. how things are, but what we needed to do was bring a model of a change theory. So it's one thing to understand how things are. It's another thing to understand how things work and how to create change in those systems. So that's where Dr. Daniel Tapanis was very instrumental. He brought to that kind of some at-learing approaches. I always like to say it rests heavily on general systems, general systems as a family of theories, which includes some interesting, really, really older theories that I still find fascinating. Those are things like game theory and cybernetics.

There's smatterings of that in there. I think it touches and it borrows from some of those early stage marriage and family therapy field theories, such as structural and strategic. So you have like Mnuchin and Haley, a little bit of satire in there for the more empirically leaning sides of change theory, but they're all basically general systems ideas of how you create change given an ecological understanding of concepts. So that was the early stages. And then as our team and as the world of neurobiology, as well as the interaction between biological states and psychological states, is that research grew and developed kind of at the same time that we're growing and developing, it's this constant search for what do we know from that field and how do we bring

that in because everything that I just talked about kind of covers everything from the community down to the relationship based and then a little bit of this this balance between psychology and the biochemical reaction. But what we're learning and constantly learning and growing from is more details on that last issue. What does that exactly mean? There's different ways that psychology and behavior and emotions impact us biologically. And then, of course, there's the interdependence between how, say, a child's biobehavioral reactivity state will impact and be interdependent with their parents or their siblings or their friends. And I think that's been the fascinating work in the last five to six years,

understanding those interdependences between people's at those multiple levels. So that's the short story of it. It's a very complex issue. So that's the theory. Then there's the practice of it. So what we do is, as you were mentioning, we have primarily been, been practicing this program in a hospital-based program setting, and that is through partial hospitalization intensive outpatient multidisciplinary teams with yourself as our psychiatrist lead.

On the youth side, we have a child psychiatrist that's a lead for all of our youth patients. We have nurses. We have therapists. We have case managers, all that fun stuff. The point of that is to bring that team together to help execute change in a family system when all those processes maybe aren't working adaptively, as we like to say. It's not that it's right or wrong. It's just the goals and the health of the family is trying to reach the way that the family is operating right now aren't achieving those goals. And that has to do with all the issues I was just talking about. So it's creating change in one or more of the levels of ecology to help push that family down the trajectory of health. Okay. And we're going to try to we're going to try to delineate

some of the theory into a more practical understanding as this episode goes on. So if a lot of that was like not understandable to you, that's okay. I think before we get into more of the practical side, there were a couple studies that really showed the value of the program. And so I'm wondering if you can speak to the study that specifically looked at catacolamine and catacolamine load before the program, after the program, or at the end of the program, and then after the program and what you found.

That was, I think, our second larger study that we did. That was a very interesting study revolving around our youth population. So these are kids with chronic illnesses, anything from cancer to a need for organ transplant to diabetes, you name it. We were looking at, we knew that the program had, from a previous study, we looked at health-related quality of life. So as families went through the program, did it help improve their overall health-related quality of life? So their physical health, their emotional health, social health. From that study, it was pretty clear from the evidence from a pilot study version

of pediatric patients that we were having a pretty important impact, not only on the kids, but also on the parents and the siblings. So the next study, the one that you're referencing, we wanted to go one step further. One, we wanted to see, okay, we know that it was good from starting the program to ending the program, but we wanted to look at do the effects that we have from ending the program. Do they maintain after our family has left the program? Because that's a common issue in the world of behavioral health where interventions are tested pre to post and we get really good outcomes, but then you watch the family go back into the normal life. And three months later, those outcomes are

diminished or are all but gone? So we wanted to watch out see, are those outcomes still there? So that was one of the pieces of that study. Then we wanted to add more of a biomarker side to it, because one of the theories we had was this issue of stress, as you're alluding to. Our theory in mend about stress follows closely this idea of elastasis, and just to make that a little bit more approachable for those of us that aren't in that world, alistasis is just this idea that we have stress responses. We have fight or flight kind of reactions. These are normal processes in the human experience of living. There's nothing wrong with that, but in some certain cases, those processes can get out of balance. So we can have too great a reaction to stimuli outside of us or too freak into a reaction

and what's really happening in the body when that's going on as the body is introducing chemicals to prepare us for that situation. That's a really adaptive kind of thing back in the day when we were kind of out in the world trying to struggle for food and resources. Nowadays, it's not as adaptive, but it's still useful in a social context to a certain degree. But what we're finding is that if individuals are having too great of an amplitude of response of stress or their responses to stress is too frequent. The body has a really hard time getting rid of the chemicals that produce that response. And when those chemicals build up in the body, you start to see actual physical responses, such as if I have a chronic illness, the progression of that is going

to be much quicker in a negative way. Or I may have a predisposition to something that's a chronic illness in that presence of all the stress chemicals is going to kick off that predisposition into something that's actually symptomatic. So we were looking at can this program actually reduce stress at a biochemical level? Can we, through these interventions, teach a person and interact in the system in such a way that you can measure chemical changes in the body? And so we did that with catacolamines. I can get into the nitty-gritty of that, but it's basically catecholamines is a 24-hour urine test that we had patients do pre-post and then three-month post again. to measure how much the stress chemicals were in their body.

And what we saw was pre-to-posts. There was a significant reduction in the amount of catacolamines, meaning there was an actual biological reduction of stress in the body after going from the program. And then what was really great to see is that when we tested again three months after the patients had left the program, they re-engaged back in life. That low level of catacolamine stress was still low three months after. I think one of the coolest parts for me on that study is there's a lot of research. there was a beginning of research at that point in time when we're doing it, but that continues to grow.

There's a direct connection between the level of catacolamines or stress chemicals, depending on how the study measures it, and a person's IQ. They're cognitive functioning, not necessarily their IQ per se, but the way that their brain is working and functioning. So with lower levels of catacolamine, you can see a person achieve much greater cognitive states. When you flood the body with stress, that's where you see people struggle to kind of focus, the memory goes, and that happened to be a critical component for us because our primary, when we started, I like to tell the story of the program started with this relationship between

our children's hospital and our behavioral medicine center hospital. And it was the children's hospital that came to the BMC that's their hospital and said, we have kids with chronic illnesses and we think they're being non-adherent with the protocol. So this child may have, say, type 1 diabetes and the A1Cs are completely uncontrollable. we've been telling the family what to do. We think they're just not following the treatment protocol. So non-adherent is the language that they would use. We never saw it that way and we don't see it that way with chronic illnesses.

We don't think that's the primary issue going on. Although, you know, the behaviors might be the same. It may be that the family is struggling to check the glucose levels and follow the diet and nutrition criteria. We come at that from a perspective of they're not being defined and not being non-adherent in that way. We think it has to do with this. catacolamine stress issue. We think that the family is under so much stress that the cognitive

functioning of the individual patient as well as the family system puts them in a state where it's really hard to follow complex treatment protocols. So in a very indirect way, the stress component changes the cognitive functioning, which makes it harder to do all those protocols that we have to do when we have a chronic illness. In a more direct way, the level of those stress chemicals in the body has a direct impact on the physical health of the body. So it was cool to see in that study that we did two things. We saw the catacolamines reduced, so the stress, the biological stress was reduced, but we also gave the kids cognitive intelligence tests pre and post, and we saw their intelligence levels improve post the program, which you can only account that to the program itself because we

weren't teaching these kids anything. This was in a school-based program. We weren't trying to impact their learning abilities in any way. It was merely just reducing the stress down, and then you saw their cognitive intelligence through fluid and crystallized intelligence improve post the program and maintain three months later. Beautiful. What was the effect size or what was the like how big of a change was that? And then what how big of a change was that drop in the catacolamines? Just nerd out on the numbers for those that understand that stuff. So on the catacolamines directly, we like to measure things in what's called the

Kohens DFX size, not to get real crazy into the stats, but it's basically, you take the normal distribution of the data and you figure out standard deviations of all and blah. So we call it a Coen's DFX size. In behavioral health research, when we get really excited about a program and we publish it in all sorts of top tier journals, you would see effect sizes like a 0.8. And effect sizes range from like 0 to infinity. So about a 0.6.7.8, we get really excited about programs in behavioral health that achieved that level. We publish them all over the place. That's where you start to see a lot of funding come in to really expand programs like that. So on the catacolamines, it was about.

about a 0.8 level change, pre-to-posts that maintain three months after. Some of the other measures that we have have much greater effect sizes on it, such as when we look at health-related quality of life, like self-reports, survey-based methodologies for our adult patient populations, we've seen in our program effect sizes that are like 3.0, 3.5, which are ridiculously high. So I think that's been very impressive for us, because I've been in the world of behavior, Health, I've worked many different programs. I'm an editor for one of the family therapy flagship journals. Rarely do you see effect sizes that high. Now, when you, okay, so there's a couple thoughts I have on that large effect size. We're comparing that to, we're not even comparing that

to a control, right? There's no weightless control in the, in these studies. So we're just looking at like the average distribution of how people normally fall into the, and what, it's the, it's the, it's the Who, it's the World Health Organization, like physical health and mental health. There's two components of this. You want to talk about the measure that we use and what I'm talking about here? Yeah, so on the adult side, you're exactly right. We use the world health quality of life measurement. It's a measurement that looks at four different domains of health, four different domains that would be impacted by an individual's physical health. One is directly the physical health domain. Then you have psychological health. You have emotional health and you have social health. So social health would be like my health is impacting my ability to form and maintain

relationships around me. Emotional health would be like my health is creating me to be in a situation where I'm experiencing depression, anxiety, whatever. So that's the measure that we use on the adult side. Yeah. And it's three standard deviations is is incredible, but you have to also realize how many hours of work that usually patients are in to get that three standard deviations. Like we're talking about not only, usually by the end of the program, people are going from pretty severe dysfunction into a place of like exercising on medications that are better and maybe having had 100 hours of therapy, right?

at minimum, yeah. We're getting into some like science wonky stuff around like psychometric measures and blah, blah, blah, but there's some other measures in some of our other studies I think are a little bit, we can wrap our minds around a little bit easier. Okay. One of which is when we're talking about the kids study, one of the things we measured with how many days the kids missed of school due to their chronic illness, right? And what we were finding is that before the program started, these kids were missing. It was 11 days of school per month, right? So if you do the math on that, there's not 30. days of school per month. You got weekends, you got holidays,

both. Wow, there's usually about 20, 22 school days in a month. So I always think about that as the kids were missing about half of their days of school due to chronic illness, which points to the point that you're making. These are kids, these are adults that are significantly limited by their physical

health at the start of the program. Then after the program, when we watch them immediately after and three months after, we see that misday of school measurement go down to about a day to two days a month, right? So that's a fairly significant reduction on the adult. side, you see the exact same numbers when you talk about how many days of work that the adult patients are missing. So they're missing about half of the days of work per month before the program,

and they'll get that down to one or two days per month after that. But we have to keep in mind, those adult patients still have chronic illnesses, right? They still have, they're still in stage four kidney disease, and they need to have significant number of visits with their physicians. So it's understandable that they have some of those mistakes. And then there was the other study where we were looking at from more of a financial perspective of what's the outcomes of a program like this. And what it's really doing is it's keeping patients away from emergency care, right? Emergency and urgent care. So their health is so bad that they are frequently having to go to the ED or urgent care to deal with their health after the program that drops to almost the

non-existent level where they're able to maintain their health with the help of their primary care, their ambulance care specialty teams. Yeah. And I was a part of this retrospective look at 107 adult patients. So this was age 18 to 80 who did an average of 25 sessions. So those sessions, remember, can be seven to three hours long. And it showed a 12-month cost savings of $16,000. And if you imagine that each treatment cost, the insurance about $285, the whole treatment, 25 sessions would be around $7,000, and the net savings

would be somewhere around $9,000. So essentially, whenever I do a dock-to-doc with an insurance company now, I say to them, look, you really want to give them the full treatment because it's going to save you and your insurance company $9,000. And I've had a couple of them be like, oh, can you send me that article? And I'm like, yeah, I can't send you that article. Because insurance companies, you know, are notorious for like, is the patient still suicidal? Why can't they just do outpatient? I'm like, because outpatient's not going to give you this fast of a result and you're going to be paying a lot more money out to emergency rooms.

And, yeah, Jesse, you have these conversations with these insurance companies, right? Yeah, I have. Yeah, it's painful. It's one of the most painful aspects of our job. I think it's important to realize why we did that. And it's the environment that you're talking about, Dr. Peter, where insurance companies are still very, when you talk about the business side of health care,

we are still very much siloed in there's behavioral health over here and there's physical health over here, even though the research world and the work that we've done is evident of that. They're connected. They're interdependent. You can't separate the two. And those savings that you're talking about are not just on the mental health side.

They're primarily on the physical health side. So by doing a behavioral health intervention, you're talking about health savings on the physical health side of that insurance and for that person, which it's baffling to me that insurance companies are still struggling to understand that. And that's why we did this work is because we couldn't get insurance companies to reimburse for the treatment that we're providing for our kids or our adults for a very, very long time. So we ended up doing a lot of these cost-benefit studies to be able to show them, you need to do this. And once we did and had those conversations and others in the field and other researchers have done. even more incredible work on this issue. Insurance companies are starting to listen a little bit. And as you launch with, you know,

on our adult side, I think we can pretty much get reimbursement from any insurance company now in our local area. The kid's side is the same thing, but we didn't start there. We didn't start there. We didn't start there. World of Behavior Health right now.

Yeah. And what, what a blessing to be able to provide for, you know, for the populations that we do. I mean, for a long time, some of the insurance companies would not reimburse. And so I would go and talk to doctors in different departments. And they'd be like, well, what do I do with this patient? Because they have this.

You know, and I think it's going to be important to make this more tangible. You know, like what we're really talking about is when stress builds up, this is this simplistic way that I understand it. When your stress builds up to a certain place, you have an organ system, which is like genetically wired to be your weak organ system. And so maybe your first organ system is your head and you have headaches. And so not everyone will get depressed and anxious first. First they'll get chronic headaches.

And then there's a second organ system. Maybe it's something like fibromyalgia. So they get chronic body pains. And then the third organ system, maybe they get like TMJ. And so they have this chronic jaw pain. And then they have their fourth organ system. And they get irritable bowel. And so they're always got this kind of stomach stuff going on.

And then they have their next organ system. Maybe it's psychogenic seizures. So now they're hospitalized and they're at the hospital and they're seeing teams that know about the men program. And they're like, oh, now's the time for you to go to the men program. And then they don't, though, right? And so they go to their primary, their doctors and finally they have like a child. And now they're in the OB clinic and they get referred to Jesse who's over there right now. And so finally, she's able to have that conversation and convince them.

You know what you really need to try this, right? and they've never seen a therapist. They have lots of reasons to not go to therapy. And so now they're having basically multiple organ failure in a stress response way, right? And they're miserable, and they get put on medications like benzodiazepines and opiates and sedating, other sedating anticholinergic medication. And so when they come to see me, not only are they having multiple organs that are impacted, but they're also on six or eight meds,

often not even for mental health issues, right, but for fibromyalgia, for irritable bowel, that are affecting their cognitive function as well. And so now we're having to pull back some of those meds, which is very uncomfortable, pull back maybe the marijuana that they're using for their pain every day. And yeah, So that brings me to Jesse.

Jesse, what do you do now? How do you even start working with this patient that I've illustrated here? Yeah, well, I think the simplest way it was that I first understood it when I started with MEND. I started as a student in 2017 and I was hired in 2018, was that we take the volume of the illness down and the volume of the person up. So to relate and connect to this person in a way that is safe and secure and interested in who they are, not what they have. And oftentimes this person is very disconnected from who they are, what they believe in, what they're passionate about, what they enjoy about life, the physical world, right? they're disconnected from these things that actually bring balance to the body scientifically.

So that's what we do in the therapy as we help them reconnect to those parts of themselves that we would call accurate or congruent that allow the body to be in more of a balanced state and that bring the stress levels down. Okay. So you talked about kind of two. concepts here. You talked about the illness narrative. People come in with my name is uncontrolled diabetes. Like basically like they introduce themselves first thing, right, as like this is the medical thing that I'm struggling with. So how do you start to shift them away from their illness narrative?

Right. A lot of these patients are relating to their world and the people in their world through the filter of their illness, like you're saying. So that's the first thing that they push forward. And what we want to do is ask them about what's underneath that, right? Who they are, what they care about, what they believe in, what makes their heartbeat. And that's a part of themselves that people aren't, you know, in their environment, people probably aren't asking these questions a lot because they're with doctors, they're with other. sick people, they're with family members who, through no fault at their own, are focusing on the illness pieces. So what's, I think, kind of miraculous to me is that this, this act of

connecting the person to the congruent part of themselves or the accurate part of themselves allows them to have this human experience of like belonging and value, which they've lost along the way and that in turn brings the stress level down and we see disease process reduced. Okay, so explain what it means to be in a state of congruence or what does it mean to be congruent? So amend one of the simpler ways is when we say when your insides match your outsides, that's the simplest way that we describe it. But I like to describe it as a, when my expression, so verbal, behavioral, physical expression is aligned with my internal experience as closely as possible in a consistent way. So what I'm experiencing on the inside is something

that I can express to the people in my world, to my environment, through my body physically, with my environment. Yeah. And so how does, or how do people benefit enough through like talking about their illness and being focused on their illness rather than being in a congruent space? Like why, how is it adaptive to do that in the first place? So before, Jesse, I want to hear your answer to that too, but just to add some context to this issue of congruence, I think beautiful job. And that's like how we see it in a very ethereal level.

But just to make it real practical, you can sometimes see patients that, say, you'll ask a patient, how are you doing today? And they'll be, I'm fine. But if you look at their body, you can see elements of fear, anger, or whatever it is for that patient, that would be a sense of incongruence, right? Where I'm telling you, I'm one emotion, but my body is actually showing up as a different emotion. That's very common with patients as they enter into a program like this where there's some socially acceptable emotions or sometimes the family has socially acceptable emotions and all the emotions that the patient experiences are going to have to be titled in that way for the family. So it may not be okay to be sad in a family, right? But that family

will be very accepting with emotions of anger. Right. So instead of I'm really experiencing sadness or grief or whatever, I may not have to be able to show that, I have to show that as anger. Now, in the first stages of developing that in the family system, that may still be somewhat congruent where the person still understands they're sad and then turning that into anger. But over time in a family system like that, the person loses consciousness of that, that disconnect. So they actually experience the anger at the sadness as anger, right? And that really messes the body and the mind.

And that's where you get the stress that's happening because what my body is trying to tell the family system is that I'm sad, right? I need you to come around me and meet me in this element of sadness. But I'm projecting off to you anger. And so now you're engaging me in a sense of anger and I'm not getting fulfilled. I'm not getting that intimate connection with my family members around what's true, what's real. That creates stress.

And then you get the cycle that just builds over and over and over again. And that cycle adds the stress in the body and on and on. So I would just put this note in this. We're seeing a lot of other programs develop where chronic illness or trauma and the prescribed methodology is something like a mindfulness approach. right to try and reduce stress through through mindfulness or something that's very similar to that cognitive behavioral therapy is another example um i think the the research on that is showing that those can be very effective for a certain level of severity if we're if we're catching that patient like what you said dr peter at the early stages then things like these outpatient kind of versions of

mindfulness CBT may be useful but what we're finding is that the higher severity level of patient it's not just the stress component the stress component's there but the stress component is perpetuated by the family system. It serves a role in the family system. So you could take that individual out of the family system, teach them mindfulness, and maybe get them a little bit more in tune with their mind, body, and emotional process.

But then when you put them back in that family system, all that work that was done with that individual is going to have to go away because they have to survive in that family system. So there's deeper levels of work to be done with certain patients with chronic illnesses. Yeah. I want to emphasize one thing that was very, very sort of learned as I observed and watching this program compared to other programs that have been a part of, was watching someone develop new skills of being congruent.

And then they go back to a family system that shames them back into a posture of how they were before. So if you develop like new skills on connection and new skills of new skills of voicing sadness and stuff in a group. And then you go back to your family and you talk in that way, often there's a rigidity and there's an adaptive way of behaving. And so they don't like that you've changed and that you're talking differently and it's threatening and it's, you know, so they, in many ways, unconsciously, they shove you back into the sick role or the old role of,

of how you were behaving. And so that's where I think the family work for me was like, wow, that really does help. Because you're bringing in now the spouse, the family, and you're teaching the patient to be congruent with the family member, not just the therapist, and teaching them how to interact and express things and then getting the family member to be able to see that and get excited or at least to be able to speak that new language as well. Can you speak a little bit about that? Maybe Jesse what you've seen there. Yeah, I think that one of the our field calls this, this, what you and Brian are talking about homeostasis, right? It's like the way that the system

operates like a thermostat, a temperature that the system operates in. And when one piece of that starts to change this system that's created by relational dynamics and all kinds of expressions and behaviors, right, that system will try to pull back into that homeostasis or that status quo. So when we bring the family in right at the beginning and involve them different ways at different stages of the model, but the whole idea is to change the homeostasis of the home so that it does have more adaptive, needs directed, how I get my needs met in a more congruent way. And so that is, you know, all, maybe it's all the family members, depending on the patient. it's definitely the patient's closest people, right? And this happens in a way that the therapist can predict for the family what's going to occur and what things are going to change.

And we have additional pieces like parent education. We have the multifamily hour. So the families are learning the language of men. They're learning how to connect to their bodies the same way that our patients are. They're learning these new expressions of their internal state and, you know, their desire. And so the illness piece that maybe helps them get their needs met consciously or unconsciously is no longer necessary, right? I can tell you how I'm feeling and it's safe to do that now. And you understand what I mean when I say how I'm feeling.

And I can also ask you for what I need and you can hold that space for me because it's less threatening. and you can hear what I need, and then maybe you can show up for me in an adaptive way, and then I feel valuable, and then you feel valuable, and then everybody's stress is lower and the illness is down. And there's this thing called, the other thing that I was thinking of when you guys were talking is secondary gains,

which are the interpersonal chaos of illness. So there are benefits, conscious or unconscious benefits, and they could be tangible relational, physical benefits to the illness for the whole family, not just for the patient. And so by doing this family system's work, we are removing, you know, we're allowing them to give those gains up because the body doesn't really want to get the needs met that way anyway, right? It's much better to get them met in a direct, congruent, accurate way. So the family system's work is essential for potentiating the change long term for the patient.

Yeah, let me bring that into a practical story. Like I remember there was one patient who like marriage would be on the rocks and she would get hospitalized. And then the family would be around her bed in this like close to near death experience. And all of a sudden like that was the cure for this family to heal. their language of love in the house maybe right it's the only place where people feel safe expressing love and connection right it's around illness maybe so we we teach them a new way right to to get that love and affection and that belonging and then it's almost like the body doesn't need that symptomology yeah i think um the the couple patients that have not gotten through the program

that I was able to follow long term. There's about two or three of them in my mind. So at some point, the gains from the illness were so large, and the family structure was so rigid that they could not give up the secondary gains. Let me make that. It's hard to, let me make up a scenario a little bit different than the actual one,

but you can imagine how this would be case then okay so you have like a 50-year-old woman who's married to a um a policeman and if she has a medical illness going on that this policeman husband gives her attention if she has anxiety or depression he completely ignores her if she has emotions he ignores her but if she has um you know a physical illness he gives her attention And so what does she do? She is, she comes, she comes an amend and she starts making progress. She starts learning the language of, and how to be more congruent, right?

But then with her new language and her, her husband refuses to come in, right, which happens from time to time. So he doesn't learn how to be congruently connected with her in an emotional conversation. And so she goes back and he, ignores her. And so she chooses to remain ill, which is sad. I've seen that a couple times. Any thoughts on that, Brian, or any thoughts on that, Jesse? Yeah, we have kind of the saying in the background. We said the family pushes forward the one in the family who's strongest. So they push forward into therapy, the individual member of the family who is actually the strongest member of the family. That person shows up

in a health care system being called the identified patient and from a health care perspective looks like it's the one that needs the most help. That's oftentimes not the case when you actually do family work instead of just dealing with that individual patient. So if that patient was to be routed through the typical processes of behavioral health would be caught with, let's say depression, right? Their primary care person says, hey, I think you might be experiencing some depression. Let's send you to an outpatient therapist. Maybe that person gets linked into a one-on-one outpatient therapy approach with a therapist who's going to use more of an individual approach such as cognitive behavioral or whatever.

But really what's happening in the family system is you illustrated it. And it's a very common story. You see the wife in the family have all these symptomologies. And the husband you describe is an individual who is really struggling with internal emotions so that being actually genuine and intimate in a relationship. It's difficult for that husband in the relationship, right? And that is the thing that needs to change. From our perspective, we would be looking at that.

relational dynamic there. How do we generate a relationship between these two individuals that, as Jesse was illustrating, congruent, right? But in a different, more common language, just we're building intimacy, true, genuine intimacy between that couple relationship. When they have an adaptive process for that and it's healthy for them, you see a lot of these other things fall apart, right? You see the negative first order problems just go away on their own. You see health improve on its own, I mean, with guidance from the physical health protocols that are in place, but you see that those protocols are now actually making a difference in improving things. So I would say that's not the unusual makeup of a patient.

That is the common makeup of a patient where it's probably not the patient with the physical health that gets sent to us, who is the one that needs the most help and support for change. It's another member in the family system who controls a lot of the power, and that's why we have to deal with this from a family system's perspective. have to bring in those family members. Yeah. Yeah, I had a couple in the OB clinic the other day. And anytime there was emotional need expressed, one of the partners moved away from the relationship.

You know, not just like physically, they did physically move away, but it was almost psychological, emotional moving away. So I don't know. It's very palpable in all of the family systems that we see. Yeah. I think you said the power dynamics. I think that's worth talking about. I think that's where some of the Adlerian stuff comes through, right?

There's power brokers. You talk about how illness can you be used as a form of control, controlling the family structure. Jesse, do you want to take a first sort of gander at this and then Brian jump in? Yeah, I think we see, you know, power, illness has a lot of power. And when I first heard that as a training therapist, I thought, what does that mean? You know, but it really does because it's a way of getting a need met from my family. without the vulnerability of emotional intimacy or without having to be genuine or congruent or

to even know that about myself. So the power is really sneaky and it's unconscious. It's not like these people are saying, you know, I have fibromyalgia so I can push everybody around in my family. But it, but it does become a, okay, so when my wife, is doing poorly, then I need to lean in and show up for her. And then she feels connection. So then her body learns that when these symptoms are present, connection is happening. And the connection is really what's needed. And then that person who is able to show up for her, maybe it's the husband in this scenario, he has that reason to show up for her. So the fibromyalgia has all this power and mediates their closeness and distance as a couple, right? So the illness is really

what has the power. And then maybe the person that has the illness identity, the identified patient, they might come to use that consciously over time to get their needs met because they feel that they are incapable of meeting their needs in another way, which is really kind of heartbreaking from my perspective. And we get to show them that that's not true, that there are ways to meet your needs outside of the illness. There are ways to have intimacy and connection and joy and a relationship outside of illness.

Yeah. Brian, any thoughts, power dynamics? I think that's a big role of our program is identifying the power dynamics and the dances that happen. We call it second order process. How do people in a system interact? Every system has their rules, and those rules generally follow these issues of power hierarchies.

And what you see in systems that develop chronic illness or any kind of what we would call first order outcome that's negative, which could be a physical health issue, but it could also be a mental health issue. It could be an addiction issue. What you see in those family systems is that the process of interaction, the dance that the family does, keeps that addiction or that first order issues such as physical health as a necessity for the family

to stick together and keep that dance going. And that dance is oftentimes driven by the power dynamics that we're talking about. There's not one set of power dynamics that's common. It's not like, you know, the husband has it and the wife doesn't or vice versa. Every family is different, but it is key to understand who's holding the power in this family system? Who is keeping the system moving through this process in a very similar way? And that's one of the first things that we teach our training therapist is we have them sit down when they're doing therapy with a piece of paper and draw out the process. So husband said this, wife said this, then this happened, then this happened, then this happened, and ultimately you get back to the top of the circle.

That dance that you can see in one conversation with a couple would then play itself out in every interaction that that family is having. Well, the medium of that dance may be different because maybe in one case in the room we're talking about an argument we had about who's washing dishes. that same dance happens when we're talking about the physical health issue, right? So it's trying to help the family understand that dance that they're doing where the maladaptive pieces of it are in making the switch in the systems that their dance looks different and oftentimes that is about power.

Do you actually say to patients like this is the power that's going on or do you use that word or do use other words? I think there's stylistic freedom in the model from so that there's, therapists can use their own artistic, stylistic approaches within side of the models. So I think some of our therapists, absolutely, that would be very common language. I'd use it all the time. Some would do it from a different language point, but still hitting the same issues and creating the same type of change in the system.

I mean, when I do it, yeah, I use the language of power all the time. One of the things about the model is a phasical model. So the first phase is all about building relationship with the patient. in that stage, I'm probably not going to be doing that. In that stage, I'm just trying to understand that dance, and I'm getting the family to help me understand that dance. Because if I have a vision of what the family is doing, but the family doesn't agree with that vision, we can't move forward.

Like, stage one is I have to project an understanding of the situation for the family that they have to agree with. Once we're all on the same page, then we can start making changes towards it. But oftentimes, like the example that you gave, I'm going to guess in a case. like that where it was a struggle point, we didn't have a buy-in together, right? The therapist and the family didn't have an agreement on what is going on currently. If we don't agree on what's going on currently, we can't change it and make change together. The tricky aspect of this scenario, which I think

has repeated a couple times in different situations, is that we would get to a certain point where a certain medical issue was practically resolved and then a new one would pop up. And sometimes you see the family member change too. So one person will get better and then another person will get sick. Yeah. Okay. So but what someone in the audience, I imagine, is thinking, but what about like chronic problems that are not going away that are real medical problems? Like stage, you know, three to four cancer, it's not going away. They're doing chemo. they're doing radiation, like how are we able to help that person deal with the meanings that they put onto the disease and talk a little bit about what I mean by putting meanings

on top of the disease and how you might change that and how changing that might change the dynamic. Yeah, I still stuck on the previous conversation because that's a good illustration of like the second order process issue, which is important for change, the model that we do in the first order thing, which is the disease typology. or the behavior. So we can take that same concept and move it to the question that you're talking about now on on our computer, which is what do you do if it's a chronic illness that isn't going to go away, right? We're in stage four kidney disease.

This model is not going to bring you from stage four back to stage one. Or if you have some kind of form of terminal cancer, it's not going to cure your cancer. This is not a cure for cancer. The point of doing this with the family is to put the body in the healthiest state possible so that, one, the disease doesn't progress any faster than it needs. needs to. In certain cases, we can put the body in a state where it stops progression altogether, but in the examples you're giving, the body's got a trajectory here. We have terminal cancer. We know what the end result is going to be. All we're trying to do is get the body as healthy as we can

to prolong that as long as we can. I think that's what we talk about too in terms of organ transplant. So if you take somebody needing a kidney transplant per se, there's a common understanding in the world of physical health that you want to prolong the first kidney transplant as far down the road as you can because even in the best case scenario, the distance and time between your birth and your first transplant, that distance gets exponentially smaller with every transplant you do. The next transplant is not going to last as long. The third one is going to last even less long. So the more you can prolong that in the first step, the longer quality of life you can be able to give that person. So with cancer, it would be the same thing. It's trying to get the family in a

healthy state to lessen the negative slope line of that progression as much as we can. Because you can still find happiness and health, even in those situations in a family. Yeah, and I think allowing the family to have this congruent, genuine intimacy opens up all kinds of joy in the present moments for the family. And, you know, I also think of like self-determination and dignity and autonomy, you know, preserving those things for the person who is terminal and teaching the family how to do that and allowing the family to kind of let that process happen. And now that they have this language of emotion and this language of how I get my needs met, they're able to be comfortable physically, emotionally, and so. psychologically with whatever is happening, even if it is catastrophic for this person with this disease process. I was just thinking, too, without giving specifics on the cases, there's been a

couple of cases where the patient has come in with a terminal disease that maybe six months is the prognosis here. We're not changing that, right? The activities like this aren't going to turn that six months into six years. That's not the point. But what did happen is keeping in mind that have a family here. So that individual came in with a terminal diagnosis of like six more months to live. But what we're able to do is reengage that family. And the family is now forever in a different place because they got to meet that last stage of life in a healthy experience and not have those kind of regrets that can hang over some other families for decades and generations to come. Yeah, like forgiveness work and, you know, healing work and

Yeah. And that and that goes to your question, Dr. Peter about meaning, right? What, what is what is the meaning for me, the meaning I make of maybe my life or of the way that I walk through this with my father or, you know, my sibling or, you know, the way I make meaning of this determines how my body responds to the traumatic loss of a family member. So the implications for all the family and for their health, I don't think you. can even probably measure that. Yeah. Yeah. I think the meaning that we attribute to things changes the stress response, the cumulative stress response.

I've seen some patients, some of the biggest surprises I've had are patients where their problems are not going away and yet they're able to make the best out of their situation and and create new, you know, new life to do things that are meaningful for themselves. You know, it's so cool too, is those families, sometimes they only need a couple sessions, you know, because they're all like ready to move in that healthy way. They just need a little bit of help getting there.

Yeah. Yeah, I remember one patient in particular. he had lost his because of his illness he had lost all testosterone it was a male patient and I remember we were in group one day where you know process group

I think Ginger was in the group she sent a couple episodes with me and on she was a men therapist as well and I remember saying like I don't think this guy's ever going to get his confidence back with his testosterone gone and Ginger turns to me and it's like what are you trying to

trying to say about us then? Like, do we just have no hope? And I was like, uh, okay. And I was, um, I was actually contacted by him about two years after the program.

And he said that he had started, uh, this like, this thing that would have been completely anxiety crippling before. He had started teaching at a high level, um, which he had never done. And it was very, it was satisfying to hear back that, in fact, he had, you know,

courageously adapted to the biological realities, which had changed for him, you know. Confidence. And to the meaning thing, we, in our teaming, we have these two-hour group supervisions every Wednesday that really infuse our work. And yesterday we were talking about the biology of belief. So like the way that we make meaning of stimuli in our environment is at the cellular level changing the way that our body works, you know, and organ systems and everything. So not just the stress response, but yeah, it's pretty fascinating stuff.

Yeah. I just did in a social anxiety episode I did. They had this study where they looked at eschatalopram, and everyone in the study got esotelopram, but 50% of the people did not think that they got acetalopram. And then they did radio tracer what was going on in the dopamine system and the serotonin system. And they found that the radio tracer was binding more tightly,

or less tightly in the dopamine system, which means that dopamine was actually working more. There was more dopamine. and they attributed that to part of the response of those patients who believed it was the belief of the medication that was going to work that created that dopamine response. And so, yeah, a lot of what we do with patients is creating buy-in that our model is actually going to work. Like, can they trust that yes, getting off of benzodiazepines is going to work?

Of course, it does work as well. you know, like to some degree, just like esotalopram worked to some degree as well. But there was that added belief benefit. Yeah, I've always been really impressed with the medication work that you and the other psychiatrists on your team do, getting the patients from so many different medications that you know are interacting with each other and having negative effects on, like you mentioned, cognition, for example. but it does take a leap of faith for the patient to agree,

especially a lot of them are, you know, anxious and fearful about changing things like medications. So. Yeah. Well, it's like very different when you're solo outpatient to try to convince someone than when you have therapists that are on board with you and what you're doing and understand. And like,

and we're operating as a team. And actually, I think our effect size is increased Brian, I think you saw this as we developed as a team and sort of had more internal you know multidisciplinary collaboration. As our collaboration increased

I think our effect size increased 100%. I have the added benefit of because I'm the director of the program. I get to see every, so we run this as you said in like IOP tracks and Ph.P. Tracks. Well, that's really a therapist running that track. A therapist is part of the head of that team. I get

to see the different effects sizes across the different therapists, right? So I know who's pulling off really good effect sizes and who's struggling, whatever. Oftentimes the struggle points, when we identify that, it's exactly what you're talking about. It's leaning on the team more. It's building that culture within the side of the team using the shared common language, shared common vision. I think if you think, Peter, if you think back to your early days of working with men, you probably had a lot of sleep with nights and frustrations, right? Just like when we bring in new therapists, they experience the same thing because we're not using, the language and culture of medicine.

And we're not using the language and culture of behavioral health. We're trying to create some kind of bridging culture and language with this man theory. And that's going to feel uncomfortable in one way for the therapist. It's going to feel uncomfortable for a different way for somebody trained in the medicine world like psychiatry. But once they come together and they buy in on the shared language and culture, then they start seeing the cases the same. They can start working together in the same way for the patient. Without that, you see a lot of the stuff that patients do call triangle.

where they'll tell the doc in a separate room because we're in a room one-on-one. They'll tell the doc one thing, tell a therapist another thing, tell the nurse the other thing. And they're trying to play that off to see, like, who's going to be my friend in this and who can I use to get what I want? That doesn't happen when you have a good cohesive team that's sharing notes and they're all working from the same perspective. And that takes time. All of these teams, every time we bring in a new therapist, it takes time to build that team.

Yeah. Let me just make that more practical. So sometimes I will see a patient and they'll show up 10 out of 10 depression, 10 out of 10 anxiety. And I'm like, do I need to start switching these meds around, being more aggressive? And I asked the therapist, like, how are they showing up in group? And they're laughing with the peers, their bright affect. Oh, they're doing so much better. But they're not reporting that to me.

And so, you know, having that collaboration allows me to see that, oh, okay, this person has gotten good things from psychiatrists worrying about them. And part of that process has been changing meds. And so there's been some patients who come into the program who have come, they come in, knowing more about medications than most first-year residents. Yeah. And they come in with charts. These are the meds I took these times and these are the side effects and there's hundreds

of side effects. and I almost have to take like a very sort of like, okay, I'm going to just connect with you about, you know, basketball. I'm going to connect with you about things that are positive hobbies. And I'm going to get a couple symptoms so I can chart well enough to put in a bill. But they come in and I remind them like most of the work you're going to do in this program is actually psychological in nature. And they want to like,

Yeah, they're breaking out of the medical model thinking that the medicine is going to be their savior. And I'm actually like, like, my ego has to be low enough to be like, okay, not being, you know, the hero of the men program. Like, if anything, like, the heroes are the patients and the therapists are doing the majority of the work. And I am like, I get the pleasure of observing the good work that is done. but in no means do I take credit for it or like, you know, I have to like take a backseat almost to be to be an observer that does little things here and there that are important, but not maybe the main pusher, you know, whereas some doctors have come in because we've, you know, we've seen doctors come in in the last couple years.

And it's like, it's almost like a narcissistic injury to not feel like they are, the ones that are creating the change. I don't want to say too much about that, but it's like you have to have a mindset in as the, I think as a psychiatrist to point the focus on the psychological shift that they're going to make

because otherwise they just, they want to, they can make illness and their medicine as part of that illness as part of that. And they want to make you responsible for the outcome or then in that case you are. And what's so beautiful about the work we do as a team, for me anyway,

from my perspective, is that the patient is the hero, right? It ultimately comes down to their decision of how they want to live and what's important to them. And so they're the ones that really do the work. And we just kind of put the breadcrumbs out there. And I mean, we talk about like owning the process, the patient needing to own the process to really feel like. like they're responsible for the change that they're creating in their life. And I think that what you're talking about with humility being important,

you know, being important to realize that we're honored to be part of this process and we're honored to, you know, be, it's a privilege to be part of this process for me. Yeah. I think you're bringing up an important point that we've noticed over the 10, 15 years that we've been doing this, particularly as we're a multidisciplinary team. We work with not only psychiatrists, but we have extensions of this that are in our ambulatory settings, whether it's maternal fetal medicine where Jesse's working or especially team center for our kids with chronic illnesses. And yeah, you can have the narcissistic leading of a doc.

I think it's rare. It's definitely out there because, you know, that is a very helpful school talent to have to grow and become at that level. But it's rare. I think what's really going on is particularly in a hospital-based setting, The doc is told that they're responsible for everything, right? If the patient's not doing well or something goes bad, it's your fault and it's your, it's your reputation, it's your license on the line. And then that gets a little overwhelming.

And so we want to then overreact by controlling everything to make sure it all goes well, right? And make sure it's all safe and free of as much risk as possible. The change here that we're talking about in our teams, and it takes every time we go into a new clinic with a new set of docs and RNs, it takes time to pivot in this direction. It's a level of trust. It's trusting that the therapist that you're working with actually can do this work. And it's not going to look clean and pretty every single day. There's a big component of this model where there's phases where we're asking patients to make changes that maybe cognitively they say they want to, but unconsciously second order

process, they don't. And they hit that struggle point and it's a push back and forth internally with them, and that can come off looking conflictual sometimes, and some difficult pathways have to be navigated there. And if the doc and the therapist and the RN are all on the same page and know that's what's going on, they can work as a team to move that patient through that struggle point. But if I'm that doc, especially a new doc who feels like I have to make sure nothing bad happens, otherwise, you know, I'm risking myself, my reputation, the hospital reputation. And we don't take the chances and we don't extend that trust down to the therapy team. And that is what if the team's not working together and there's not trust there,

the patient isn't going to experience the benefits that they could. Yeah. And it starts really small. Like I know at the clinic for me, we're, you know, we're two years in, but it's like small things like this patient wasn't eligible for IVF and now they are. could you put that referral in again? Oh, yes. You know, Jesse's doing this with this patient. We can make it happen faster without an added appointment for the patient. Or, you know, I have this patient who I really want you to see Jesse. She has postpartum depression, but her family's in Korea. They're not back for a month. And then me just calling that

patient, you know, once a week and leaving voicemails until she's back. And then the doctor can see that. And now, you know, we're going to see the couple in the baby all together. now they're back from Korea. And the doctor's really, you know, kind of gaining trust in the work. And then, you know, same doctor, second patient. The second patient needs time off. And I'm seeing the patient once. And I'm just writing a note to the doctor. This is what I'm seeing.

And the doctor's like, let's get more time off. Let's do this. You know, let's do it right now. But those things take time. They take time. And like you said, Brian, building trust. Yeah. yeah i think i think um there's yeah trust trusting that uh one of the other things that helped build

trust was seeing the men therapists really go the extra mile with some of the family therapy and you know a lot of that is unbillable time but we just kind of like decided as a program because that's part of our model even though the insurance companies may not pay for that time. Am I right? The insurance companies don't always pay for that time, Brian? Never. No. We do that without direct reimbursement, not because we need to to get the changes that the families are possible to achieve. Yeah. So I think that has really been something that having worked with other programs, like I didn't feel like there was a culture of that. And so I think it's a good culture because, you know, I mean, people are, even providers where we get

tired at times and it's like going that extra mile can be a lot but i think creating a culture where that's part of what we do is helps build trust with me that oh okay like there's there's some big buy in here you know this is this is important it's why i commute every day to be here i mean this culture i think is very special the culture here and the energy that is created for me as a clinician that then i believe leave is transmitted to students and maybe to even people above me and the organizational structure. And then the patients feel it too. It's this idea of like if you're really willing to take responsibility to change your life, I'm going to do everything I can to help you do that. And that, I mean, that's what we do here. We have like parent education. We have support groups.

We have, I mean, none of this stuff's reimbursable. But that actually can be very energizing when you're exhausted. It can be very energizing to see the health that comes out of that. Yeah. Some grade A leadership for me, Brian, I'll have to say. Yeah, it's top down. It's tough down. I was telling Brian and Daniel, they can't ever retire,

not until I'm ready to retire. No, I think, you know, all joking aside, that is a key factor to getting something like this going in a system. This has worked very well at the Loma Linda system because there's been support above us from the medical teams here to the CEOs and down. We have begun a process of trying to push this model out to other hospital systems and been working with some other hospital systems in northern California and Chicago. And it's becoming very, very evident to me that to do this kind of work and to provide a team-based approach that we're talking about, really requires major system change within hospital systems or larger health systems to be able to do this well and create the environment where these multidisciplinary teams can really work

and thrive and do good work for patients. Yeah. And I think, you know, we talk about culture and prising culture and, you know, it's, and that, you know, hasn't always been the case, right? I think that we've, we had some tough years as you kind of like linked up. And, um, and, but I think that over time, it's, it's improved. And I think the outcomes improved with it. Yeah. And I think that's been enjoyable. So yeah, it's kind of like a part of my week, you know, and it continues to be part of my week despite some, some increased distance. And, um, it's been fun. So I'm glad. I'm glad we had the time. to come on and talk about this? Is there anything kind of like that's still lingering in your mind,

Brian or Jesse that you want to, or final thoughts that you want to put out there? I think the next state, like this is a demonstration of behavioral health integration in one way, right, where you've got therapists and medical and all that stuff working together. So I think this is this is something that a lot of systems are thinking about and the healthcare system is moving in this direction. So, you know, a lot of lessons learned in that area. unique to our experience here is we're using this men theory as the way to set that culture for behavioral health integration, having the men theory be part of the teams that they have a shared vision, understanding, language. I think that's going to be the next stage because we're seeing a lot of systems move heavy into behavioral health integration, but I think they're going to find that you need something like this. You need that common theory and understanding in those teams for that to really work well.

So we're very excited that we're able to, we started that here and we're moving that out into all the different Loma Linda systems. And we're working with a few others to try and help and support that kind of movement going forward. So healthcare is going to be interesting in the future. It's a changing world. And the pandemic really, really increased the speed at which a lot of things were changing. So it's exciting to be a part of behavioral health, it's exciting to be a part of health care, as we all understand these things from a slightly different perspective now. one thing that that brings to my mind is I thought that going to Zoom, because for a while,

we were 100% Zoom in all of our groups, which is totally new for us, right, during the pandemic. I thought the effect size was going to go down, but it actually didn't. Partially, I think, because we had more days, right? Or what were you saying about that, Brian? Any thoughts on that? So, yeah. like day two of the executive orders of like shut down all in person we had to pivot and go online and we used zoom for that we saw dramatic increases in the effect size in zoom immediately but then about six months out they just tanked they really just tanked and what we decided was that was that was because everybody our society had changed and everybody was like okay we're all in on this technology thing but then as we got into month six. It was like, no, patients still have these health needs and they need to be here in person.

And we really have learned that the in-person work, much more effective than the online work for the level of severity of patients that we're talking about. I think it's a different story. If we're talking about true outpatient, I think there's some arguments there that telehealth and all that stuff has a role. But when we're talking about this level severity of patient, we've given up on the online. We use it as an adjunctive tool so we can do things like support groups and whatever that allow patients from a larger geographic. area to participate, but in the core work that we do, we have pivoted all the way back to in-person because it really is a relational-based kind of approach. And you lose a little bit of the relationship through technology right now. I try to see as many patients as we can on our team

at the clinic too in person. They're used to having that telemedicine option, but we try to get as many of the moms and their families in person. Yeah. I'm just excited to be a part of the integration. Yeah, Jesse, any final thoughts? That's it. Just that I'm excited to be a part of it. I'm excited to continue to learn and teach others and help people.

Yep. Great. Well, thank you guys for coming on. Maybe we'll have a part two. And there's so much that we could talk about. I will link our program. in the show notes and we'll have a little article that goes with this that cites some of the studies that we've been a part of in the men program so if you want to learn more about it you can

start reading the studies and then i think we're always you're always looking for like new interns and stuff so if you're in the am i right about that or is there once okay now i'm not talking about like a hundred people signing up but like you know how many how many per year do we have come through intern-wise uh but locally here about 10 to 12 and then there's other sites too like I said there's northern California site that we support in the same way yeah so if that's if that's an interest of yours you can reach out to me through my website and I'll put you in contact with Brian and if you have if you are practicing locally in the LA area this is a program

you could send an occasional patient hopefully we're not you know our wait list isn't too long. Right now, I don't think we have that much of a wait list, but that might pick up, depending on the season. So yeah, we'll leave it there for now.