What We Know About The Transmission of Intergenerational Trauma – Dr. Rachel Yehuda – HPP 59

SUMMARY KEYWORDS

trauma, ptsd, people, treatment, conversation, biologic, studies, holocaust survivors, questions, challenge, life, understand, rachel, trauma survivors, concept, therapists, stress hormones, approach, thinking, parent

SPEAKERS

Dr. Will Van Derveer, Keith Kurlander, Dr. Rachel Yehuda

 

Dr. Rachel Yehuda 00:00

I think that what complex PTSD helped us get in touch with is a very important aspect of the conversation, which is when something happens in the course of development really matters a lot. The same event, occurring in adulthood can play out very differently if it occurs in childhood, and we know this by studying Holocaust survivors.

 

Keith Kurlander 00:29

Thank you for joining us for the higher practice podcast. I’m Keith Kurlander with Dr. Will Van Derveer and this is the podcast where we explore what it takes to achieve optimal mental health. Hey there, welcome back to the show. A good amount of this show is dedicated to the exploration of trauma and how does psychological trauma specifically impact our lives and what is trauma? What is psychological trauma? And how does that show up in the body in a physical organism and the nervous system? How does it show up in psychology and how does it show up in our behavior? Today we’re going to have an exploration into how trauma is passed down from generation to generation. So sometimes we call that intergenerational trauma. And we’ve got an amazing researcher that’s been involved in the space of trauma research for decades. She’s done some amazing research on the epigenetics of trauma and what we know and a lot of what we don’t know about what we could say as how different markers might show up over the course of generations, when we look at trauma. So we’re going to get into a really interesting discussion today about trauma being passed down from generation to generation when we get into the discussion about what do we know and don’t know about. And also, we’re going to talk about trauma treatment and where we need to go in the future. And so it’s a pretty exciting conversation to have. And, you know, obviously there’s a lot to learn here. So very excited to have this conversation. Dr. Rachel Yehuda is a professor and vice chair of psychiatry and Professor of neuroscience at the Icahn School of Medicine at Mount Sinai. She is also the mental health Patient Care Center Director at the Bronx Veteran’s Affairs, which includes the PTSD clinical research program and neuro chemistry and neuroendocrinology laboratory at Mount Sinai and the James Peters Veterans Affairs Medical Center. Dr. Yehuda is a recognized leader in the field of traumatic stress studies. She has authored more than 450 published papers, chapters and books in the field of traumatic stress and the neurobiology of PTSD. Her current interests include PTSD treatment innovation, PTSD prevention, the study of risk and resilience factors, psychological and biological predictors of treatment response and PTSD, genetic and epigenetic studies of PTSD and the intergenerational transmission of trauma in PTSD. She has an active federally funded clinical and research program that welcomes local and international students and clinicians. Let’s welcome Dr. Rachel Yehuda to the show. Hi, Rachel, thanks so much for joining us today on the show.

 

Dr. Rachel Yehuda 03:33

Oh, my pleasure. Thank you.

 

Keith Kurlander 03:34

Yeah, it’s really great to have you. I thought a great way to start is just to have you introduce a little bit. I’ve been following your work actually for a number of years but I’d love for you to just introduce, in recent years, what you’ve really been focusing on in your research and what you’re really getting interested in and what you’re thinking about lately. Obviously, this talk has a lot to do with the conversation around trauma and we have obviously a lot of questions for you but why don’t we just start off with hearing where you’ve been in the last few years?

 

Dr. Rachel Yehuda 04:04

Sure, I’m happy to tell you. I’ve been working on Post Traumatic Stress Disorder for decades now, really a long time. And I started with one of the first groups that were doing very early work, the biology of PTSD, then a new and controversial disorder, and really have spent a lot of time trying to define, if you will, a biological phenotype or characterization of what Post Traumatic Stress Disorder looks like in the brain, in terms of hormonal changes neuro chemicals, things like that. This work led us to try to look for biomarkers that could be measured that might be useful clinically, and led us to trying to identify biologic treatment targets that could be the basis of novel therapeutics or novel treatment approaches. And as Science got more exciting in terms of methodological offerings, we have more recently begun work, where we are trying to examine kind of the convergence between blood biomarkers that we have developed and biomarkers that might be present in induced neurons and we can use stem cell technology now to take skin cells from people and induced neurons and stimulate those neurons with stress hormones as we do with our blood cells and really look at that. I’ve been interested in the really persistent effects of trauma, including to the next generation. And in terms of treatment options, we have really tried a lot of things based on some of our work with stress hormones, and also other approaches. But most recently, I’ve become interested in the possibility of psychedelic psychotherapy for post traumatic stress disorder and we haven’t pursued it yet but we’re getting started to kind of put everything together in terms of everything that we’ve learned about the biology of trauma and PTSD and try to get a more coherent treatment approach as a result of all that work. So that’s what I’m up to.

 

Dr. Will Van Derveer 06:20

Thank you. I’m grateful for, as you know, I’m a psychiatrist, and I’ve been following your work for at least a couple of decades. And it’s just, it’s very inspiring to get to have a conversation with you about what you’ve learned over this time.

 

Dr. Rachel Yehuda 06:37

Thank you. That’s nice.

 

Keith Kurlander 06:39

I’m a psychotherapist, Rachel, which I don’t think you knew. So I’ve been in trenches with clients and doing a lot of trauma work over the years and I’m very fascinated by this intergenerational link. And you know, what we know, what we don’t know, and what I’m seeing in the office over the years, and just how more and more as I clue in to this possibility that trauma exists now over generations and not forming a lot of opinions about how that happens, but more so just how do we deal with that and address that? And how do we spot that even in our patients? And so I’m just curious, you know, just any reflections you have on what I’m saying about that, and because you’ve obviously spent some time with it.

 

Dr. Rachel Yehuda 07:35

Yeah, quite a lot. That whole area of research is so called intergenerational trauma. Some people call it ancestral trauma. That work began really quite by accident for me many many years ago, when we were studying Holocaust survivors developing a clinical program for Holocaust survivors and getting phone calls from their children insisting that they were casualties of the Holocaust too. And we didn’t at first understand it, but then we decided to study it and ask for some real clarification from people that we were seeing about what that meant to them, and how the trauma of the parent impacted them. And at first, it was just the regular stuff, you would imagine that if you have a parent that is, him or herself, traumatized, this might affect their parenting and might affect the way they see the world, their level of optimism. Just kind of very psychosocial explanations for the phenomenon. But as we began to look at some blood changes, we saw that there were very similar changes in Holocaust offspring as in patients with let’s call it first generation PTSD. And again, could still use the psychosocial explanations for this but adult children of Holocaust survivors described being raised in homes that were sometimes very dark and sad. And so that’s, it could be traumatic or certainly stressful. But as the field started to give us more molecular tools for looking at molecular mechanisms, epigenetics, gene expression, we began to ask questions about what might be the origin of some of the biologic changes we were observing. And everything is very correlational, cross sectional, not the kind of work that if you were designing it from scratch prospectively you would do, but we did ask those questions and being, finally made a big impact when we showed that there were epigenetic changes in the adult children of Holocaust survivors that we’re on a similar region of a gene as we found in their very own parents and that kind of changed the conversation, that kind of got people’s attention a little more because it provided the possibility that there may be effects of a trauma in a parent that are actually passed intergenerationally or that something happens at a critical time in a parent for the mother it might be during pregnancy or it might be early, before puberty, that might affect the oocytes, and then after conception kind of influence the fetal placental interactions and result in enduring changes. So what do you do about that? Well, the first thing is you try to understand it. It’s number one validating that people had an understanding that the things that happened in prior generations to their parents and grandparents and maybe even further on down the line matter in some way are relevant not just as a historical narrative, but as a biological reality. So that seems very important. So that’s what to do first. But the second thing is that you try to understand it. And I think one of the biggest challenges of this work is to ask the question of whether these epigenetic or molecular changes that we can measure, though we don’t know how they got there exactly, whether these constitute really resilience markers or adaptive capabilities, or whether they increase vulnerability to psychopathology. And what I would say about that question, although people do not like to hear this is that it’s both because we like to have one or the other. We like to know whether something is good for you or not good for you. And I think that’s been very interesting and challenging about this intergenerational work is that the concept of really being affected by generational trauma, or even if something was passed, which is a theoretical possibility, but we have not demonstrated the mechanism, what that would mean. Are you being given a gift or are you being given a liability? And again, the answer is that you could be given both; it depends on the circumstance in which you have to use this gift. We can imagine that if your ancestors, your mother, your parents had to fight for their lives, they might want to transmit something that might help an offspring fight for their lives. But that would be a better gift if the offspring were indeed fighting for their life and not in a situation where they don’t need to be that on guard or vigilant. So, again, trying to work with what you’ve been given clinically and understand the upsides of it and where it can increase vulnerability. When I speak to clinical audiences, sometimes, you know, I’m aware that the material can get technical, I feel compelled to always explain it because I don’t like how simplistic the conversation can be sometimes. Imagine a father giving his seven year old a sharp switchblade for his first day. In one sense, that’s a terrible gift for a seven year old child, because the most likely scenario is that the child might hurt himself. Let’s say they’re in gang violence or let’s say, the families in the middle of being displaced or in a war or surviving the Holocaust in the woods. Then a switchblade might really make the difference between life or death. So when we talk about the biologic changes and even some of the epigenetic changes that we may see in adult children of trauma survivors, we’re just talking about a knife, right? We’re not necessarily talking about whether the knife will end up serving someone in a positive way, or end up causing more of a vulnerability. So that’s an incredibly nuanced way to approach biology. But I think that in order for us to have any kind of real conversation about some of what these findings mean, that’s the level that we’re gonna have to engage in, you’re gonna have to resist thinking about a biologic process, that it’s maladaptive versus adaptive, or that this is part of a pathology versus parts of resilience, and understand that just the fact that the body is able to kind of make changes in response to trauma or even be able to pass some of those changes on is in itself evidence of remarkable adaptational capabilities.

 

Dr. Will Van Derveer 15:09

That makes a lot of sense. It actually has me thinking about, and please correct me if I don’t have this right, Rachel, but it has me thinking about the work around cortisol receptor sensitivity. I believe it is one of the findings that has been shown in children of trauma survivors.

 

Dr. Rachel Yehuda 15:34

The very, very first work that we did in PTSD was really about showing that the glucocorticoid receptors are more sensitive. So what this means is that the system is remarkably adaptive, that there are changes that occur in response to trauma that probably represents some attempt to recalibrate. The experience of trauma is really overwhelming. And the stress hormones are involved in almost every single type of activity that your body goes from being involved in mood, cognition, inflammation and cardiac function. Really, stress hormones affect so many things. And so the idea that there are changes in sensitivity that might really offset in some cases, extreme damage from stress, or in other cases, really promote greater resilience is a really complicated idea, but it feels like a true idea because I think that when you start to speak with trauma survivors, you don’t get just this monolithic, everything about trauma is bad, you really need to talk to trauma survivors. Many of them are able to have taken positive lessons away from even the most adverse experiences.

 

Dr. Will Van Derveer 17:08

I think that’s a really important aspect of this conversation is the meaning making around what we call traumatic experiences.

 

Keith Kurlander 17:21

And, you know, it brings a reframe, which I think a lot of the thought leaders in the trauma space are talking a lot about right now and two more post traumatic growth models. And I had a conversation with Peter Levine probably eight months ago. And he said out of the thousands and thousands of individual sessions he’s done, almost everyone came out, basically saying that they grew from the experience.

 

Dr. Rachel Yehuda 17:53

Yeah. Sometimes in a painful way, sometimes very legitimate to questions whether the experience was worth the growth. So, I mean that’s a really fair question for anybody to ask themselves. But the idea of finding some way for the experience, to then allow someone to do something that they never would have been able to do otherwise, or think about things in a way that would not have otherwise been possible that’s when we start to be able to grow as a result of having undergone the experience. And so many trauma survivors want to turn around and have this very profound instinct of trying to do something beneficial for people who have been exposed to the same traumatic experience. So I think exposure to trauma can deepen our empathy for other people. That’s not the first thing that happens. The first thing that happens though, is people become very self focused, because they’re going through something terrible, but eventually, I think there is this other aspect where you can really, really reach out and touch someone’s humanity. Because you yourself know what it’s like to really feel.

 

Keith Kurlander 19:20

I’m curious, Rachel, what got you so interested in PTSD research?

 

Dr. Rachel Yehuda 19:25

Well, yeah, I don’t have a personal story of trauma to tell you about that. I began studying stress hormones in graduate school, I was doing laboratory based work and models of stress. And it was in the 80s, I guess a long time ago, and the big questions concerned, how stress hormones that are released peripherally from the adrenal gland can revert back and influence the brain which when you think about it is a wildly profound idea that the two way street between the brain and the endocrine glands, right, where there’s a real modification. And so that was the time it was just a very early study on that. But I really felt that I wanted to apply this to people. And so somewhere towards the end of my being in graduate school, I was looking for postdoctoral opportunities to apply this knowledge to stress which seemed like very universal and ubiquitous problems. And I ended up at Yale medical school, in the laboratory of John Mason and Earl Geller, who were actually the people that published the first biologic study of PTSD in 1986. So that was exciting for me to learn about post traumatic stress disorder. I didn’t know what that was. And of course, it was a very challenging concept because the ideas about stress at the time were that after the body is done responding to an acute challenge after the stressor is over, there are attempts to kind of recalibrate and go back to normal. People talk a lot about fight or flight, which is a classic stress response. But the hormones that are released in fight or flight will come back to normal within a few hours after a stressful challenge. A Post Traumatic Stress Disorder was a concept that wanted you to believe or know that there is something that happens outside of fight or flight that lingers that lasts for a long time, in addition to mounting a hormonal response that helps you cope with the immediate needs of a challenge which are basically to stay alive. There’s often some other things that happen, that are more transformative that are not based on just going back to where you were. It’s like there’s two conversations about stress. One is the conversation that the body knows how to deal with stress. And the fight or flight response is completely elastic, and allows you to mount a stress response at a cheap, call it homeostasis to go back to where it was. And then there’s this other aspect that says, No, no, I’ve got to learn from this. I’m not the same. And I can’t approach life exactly in the same way. So it’s the coming together of this idea of a short term challenge, coupled with what happens in the long run that was, to me, a very compelling biologic mystery. And given that the very first biologic finding by John Mason and Earl Geller was the low cortisol. That was almost a paradox. Fight or Flight. We talked about high cortisol levels. So, It just felt like there was a very juicy story here to pursue. And basically, that’s what we’ve been doing.

 

Dr. Will Van Derveer 23:09

And we have a couple more questions around, you know, just bringing so much depth of experience that you have to this conversation, one being this construct of PTSD. And I think I just would love to hear your perspective on how we are thinking about what’s wrong with that construct in the first place.

 

Dr. Rachel Yehuda 23:34

Well, I don’t know if I would use the language of what’s wrong with it. I think in some ways, PTSD is a victim of its own success. Right? In the beginning, when PTSD got started, the mandate was to try to let people understand that there were longer term effects of an exposure because that wasn’t really In the Zeitgeist, and that wasn’t really in science. We knew a lot about fight or flight. We knew a lot about what happens when a threat is ongoing or even chronic. But this idea that things could keep going. That’s a traumatic event that initiates a cascade that continues long after the event itself has resolved or initiates biologic transformation and psychological change. You know, that was a hard sell. And, again, it’s already been 40 years since 1981 diagnosis came out. But I remember the controversy around the diagnosis. So people who were promoting the idea did a great job because 40 years later, I think that the concept of PTSD is an overly pervasive concept. Epidemiologic studies show that a far greater proportion of people are exposed to trauma then develop PTSD. So PTSD is described as one kind of response to trauma. And we shouldn’t make a mistake in the field by thinking about PTSD as a binary variable. You are either fine after trauma or you get PTSD. A lot of different kinds of changes that can occur following trauma exposure. So a problem is trying to use one concept, a one size fits all, off the rack concept to try to explain the highly personalized and individualized changes that can occur in a given person. So it’s important that there’s a syndrome, if you will, description that is universal. At the same time, I think it’s important to give people the allowance to express a highly individualized response to challenges from traumatic stress.

 

Dr. Will Van Derveer 26:06

Right. Go ahead, Keith.

 

Keith Kurlander 26:09

Yeah, I think that, you know, obviously there’s this ongoing conversation in the DSM now around, we have PTSD, and there’s some push to have other diagnoses that include more of a spectrum approach, complex PTSD and other types of ways of viewing this, which is, it sounds like that’s what you’re speaking to.

 

Dr. Rachel Yehuda 26:31

Yes. I think that what complex PTSD helps us get in touch with is a very important aspect of the conversation, which is when something happens in the course of development really matters a lot. The same event, occurring in adulthood can play out very differently if it occurs in childhood. And we know this by studying Holocaust survivors. Some of whom are very young during the war, and some of whom we’re a lot older. So how a trauma hits you developmentally, the other aspect of complex PTSD is repeated traumatization that sometimes it isn’t just a moment in time, a single episode of interpersonal violence or war that can last over, maybe longer, circumscribed period of time. Maybe complex trauma can also speak to the idea that you could grow up in an environment where you’re constantly assaulted and confronted by challenges, so much so that they kind of become part of who you are and you lose your perspective almost about the fact that it shouldn’t be this way, right? So it certainly has me to suffer this kind of abuse sometimes it’s done by people that you love and trust. So I think complex PTSD introduced a very important nuance, more than a nuance and a very important idea of dose of trauma, timing of trauma and development, nature of trauma, repeated traumatization, and all of this really adds to the conversation about the expectation that a single described syndrome would fit a wide gamut of responses that people might have to a wide range of circumstances.

 

Keith Kurlander 28:34

Yeah, that makes a lot of sense. I’m really curious about your thoughts around treatments, and particularly the conversation around psychedelic assisted psychotherapy, of course MDMA for trauma and your thoughts on it and where we’re headed in terms of treating people with these conditions.

 

Dr. Rachel Yehuda 28:59

Well, I can tell you what appeals to me about the concept of it. I think that current treatments of PTSD, particularly the gold standard cognitive behavioral treatments, they sometimes assume a lot. One of the biggest assumptions that are made is that a person is absolutely in touch with what the trauma is and can walk into your office saying this is what happened to me. And there was a clear before and clear after. And I understand the events very carefully, you know, under those circumstances, and that my symptoms really have to do with the fact that as a result of the event, I think differently, I have a lot of recurring thoughts, nightmares avoidance. So a cognitive behavioral approach might be very well suited for a clear problem like that. But for many people, the struggle is even trying to identify an event from maybe many events that really changed the trajectory of their lives, or that really mattered in a deep way. And so, again, for people that have maybe started early in life, experiencing adversity or people that have really been challenged in many different ways, people that might not have a very good narrative to themselves about why they are suffering, and you know, aren’t necessarily convinced that their current suffering is a result of any single exposure to those people you need, maybe a different approach and an advantage of psychedelic psychotherapy model is that it doesn’t presume specific trauma but allows the altered state of consciousness and two therapists by your side to guide an exploration, to kind of see what gets identified under a completely conducive date, psychologically for that kind of an exploration and provides a good period of time, these are eight hour sessions for traumatic material that might be a little slow usually in appearing to appear. So again, we are not doing this yet. We’re very excited to initiate these studies. It takes a lot of preparation, and we are in the preparation phase. But there was something about it that appealed to me, because it is so directed by the trauma survivors. And I think that when it comes to suffering as a result of exposure, a lot of things are a blur. And I add to this part of the conversation of intergenerational trauma, which I think adds a lot of valence. And sometimes people experience hardships from an event that objectively doesn’t seem that poignant, but becomes far more so in the context of parental or ancestral experience like immigration and war or something that the family struggled with. And so being in a state where there are no expectations of the trauma so you don’t have the narration and you don’t have to see them, you just let it come and you stick with it. And time is not up in 15 minutes or 90 minutes. It just seems like something that I would like to try on behalf of trauma survivors, particularly the ones that have failed with other approaches.

 

Dr. Will Van Derveer 32:48

Thank you, Rachel, and are you at liberty to talk a little bit about what protocol is going to look like to VA what you’re going to roll out

 

Dr. Rachel Yehuda 33:00

No, not yet. We’re going through approval processes right now and we’ll be more than happy to talk about this specific at another time. But yeah, we are definitely working with math to develop a protocol that we’ll be able to test it. We’re interested in the scalability of this treatment, how to make it more adaptable, so that it can be administered to a large number of people.

 

Dr. Will Van Derveer 33:35

I’m glad that you’re paying attention to that aspect of it because it’s going to be a big challenge of how to scale availability of this type of treatment because of the two therapists model and all the hours and it’s going to be challenging.

 

Dr. Rachel Yehuda 33:51

That the challenge of all of our therapeutic approaches is something called treatment matching. We have a lot of different approaches out there. What we know for sure is that not everyone responds to everything, or to any single thing. But surely it can’t be random that one person responds well to one type of therapeutic approach and another person responds well to another. And what we have to do now harness the best of what we’ve been able to learn using our molecular and endocrine and neuro imaging tools, and really be able to use those tools to match people to the appropriate treatment and be able to monitor their outcomes not only psychologically, but really from a biological perspective. And so, again, you know, we shouldn’t go into any exciting treatment being naive that it’ll work on every single person. I think that just sets us up. So what we need to do now is kind of regroup to ask the question of how can a therapist know what is the best possible algorithm for any specific patient? Because the way that it is now, most people go to therapists and the treatment that they’ll get is the treatment that the therapist knows how to do, what he feels comfortable doing.

 

Dr. Will Van Derveer 35:22

That’s true.

 

Dr. Rachel Yehuda 35:23

There’s nothing wrong with that, per se if it were all random, and if it were all trial and error. But what if it isn’t? Right? There is a more precise way to understand to use science more efficiently and effectively to be able to determine what is the best method for getting to a transformative change. And, notice that I said transform with change because I think we also want to think about what treatment outcomes look like. Whether the big picture involves reducing symptoms or getting a decline in symptom severity, or really allowing people to make positive changes in their lives and get to another level, cross over to the other side and start to live their lives again. So we really want to think about that, as well as what the goals of therapy are in studies, you’ll read in the literature, a treatment, quote and quote, works for PTSD. If there’s a reduction in symptom severity, usually as little as 12 point times on a PTSD scale. But when people say they’ve benefited from therapy, usually they don’t just mean that their symptoms get better, they mean that they’ve been able to sort of unstick themselves from something that has prevented them from moving forward in a positive way. So can you not feel pleasure? Can you now embark on a good relationship? You know, pursue something that you love doing while not feeling guilty that you survived? Something and others didn’t in a way that lets you really view what happened as a way to honor previous losses. It’s so much more than, you know, having fewer nightmares, although obviously having fewer nightmares is important.

 

Dr. Will Van Derveer 37:20

Reduction is the beginning of the process, but not the end, as what I’m hearing you say.

 

Dr. Rachel Yehuda 37:25

It’s a good beginning. And I think that we have, I think we really want to offer hope to trauma survivors, that there is another side, and we have to help them understand what that looks like. And I think that people will engage more in mental health because that’s really what we have to do, we have to get people very engaged, and then explain exactly what they need to ask for what it looks like to heal and get better. When I started my career. A little was known about PTSD and trying to get people to go to treatment for it was really hard because they would say, why should I go and talk about something that happened in the past? You can’t change the past, right? And it was really up to us to explain why you have to talk about the past, even though you’ve changed it. So it’s just a matter of getting the concepts down right.

 

Keith Kurlander 38:23

Yeah, that makes so much sense. I know that you do have to get going here. So I just wanted to really thank you and really appreciate the work you’re doing. They’ve been pretty influential in my own work as a professional and personally and I think it’s really, you’re having a large influence in understanding really human suffering is what we’re talking about and how to help people. And so I just want to thank you for that as we wrap up here.

 

Dr. Rachel Yehuda 38:54

Wow, thank you. That’s a lovely thing to say. And thank you for your good work and for doing this podcast.

 

Keith Kurlander 39:01

Great. You take care.

 

Dr. Will Van Derveer 39:03

Take good care.

 

Dr. Rachel Yehuda 39:04

Thank you.

 

Keith Kurlander 39:08

Well, that was quite fascinating. Getting to talk to a researcher, one of the most published researchers in the PTSD space, and getting her to take on what do we know right now about PTSD? and What don’t we know and what where do we need to focus our energy to learn more? And as you may know, if you’ve been listening to the show, I have a deep professional interest in trauma work, but also a personal interest from my own upbringing and what I’ve overcome. And this concept of the post traumatic growth model. Trauma does not have to be viewed as a pathology that will be with us for the rest of our life that we can learn and grow from our experiences that we find to be horrendous at some point in our life or challenging or completely overwhelming that those experiences later in life can be something that we grow from and gain insight from, and learn about ourselves from and move forward in our life in a stronger way. Now If you like this information and you want more, you want more information on optimizing your mind, whether that’s about your career, and how you want to relate to it or relationships that you’re in, that you’re having trouble seeing clearly, or your financial health, or your spiritual health, send us your email, at email dot psychiatry Institute dot com (email.psychiatryinstitute.com). That’s where you will go to this forum. For five seconds, give us your email and we will start sending you immediately great videos and emails and all kinds of things on how we are going to figure this out together to live in optimal states of mental wellness. We look forward to connecting with you again on the next episode of The Higher Practice Podcast where we explore what It takes to achieve optimal mental health.