Transcript: Dr. David Rabin Interview on Stress, HRV and Psychedelics

Transcript: Dr. David Rabin Interview on Stress, HRV and Psychedelics

What follows is a transcript for the podcast: The Neuroscience of Stress: Strategies to Relax the Mind

Sub-section topics within the interview include the following:

  1. Definition of Parasympathetic vs. Sympathetic Response
  2. Learning to Cope with Stress
  3. Inheriting a Predisposition to Stress
  4. How Role Models Shape How We Handle Stress
  5. Preventing PTSD from the COVID Crisis
  6. How Heart Rate Variability Impacts Stress and Wellbeing
  7. What You Can Do Now to Minimize the Impact of Stress
  8. About the Apollo Neuro Wearable Device
  9. Therapeutic Use of Psychedelics 
  10. The Importance of Setting with Psychedelic Use
  11. MDMA, Ketamine and Psilocybin in a Clinical Setting
  12. Psychedelic Assisted Therapy via Telemedicine 
  13. Reprocessing Trauma through Therapeutic Use of Psychedelics 
  14. Other Powerful Tools for Mental Healing
  15. About Dr. Dave Rabin and Apollo Neuro

Definition of Parasympathetic vs. Sympathetic Response

Heather Sandison, ND: Welcome to Collective Insights. I'm your host today, Dr. Heather Sandison, and I am joined by Dr. Dave Rabin. Thanks so much for coming to join us today.

Dave Rabin, MD, PhD: Thanks so much for having me, Heather. I really appreciate it.

Heather Sandison, ND: You're welcome. You study a lot about stress and anxiety and the effect that that has on the human condition. Can you tell us, can you just break down, the parasympathetic versus sympathetic response to trauma and stress and what that looks like in the human body?

Dave Rabin, MD, PhD: Absolutely. I think if we were to understand any one thing about stress and the way that we respond to it that's the best place to start because these systems that you mentioned, the parasympathetic system, which is the technical medical term for the recovery nervous system, which is triggered by safety, is responsible for managing all the things that our bodies do when we're feeling safe and when we're in a position to not necessarily be concerned about survival. So the things that are activated when we feel safe; our reproduction; digestion; creativity; sleep; energy recovery; immunity, very important right now; and all of the things that our bodies do to restore themselves so that when the threat comes we have the best chances of getting out of that situation and surviving.

That system, that whole system we just talked about, the parasympathetic system, is literally triggered by safety. So anything that is a safety stimulus or something that makes us feel safe in any way will start to turn on that system of creativity, reproduction, energy recovery, et cetera. That's really, really, really important because that's how our bodies maintain balance and maintain a sense of feeling well and of performing well and feeling rested and all of these things that we value in our day-to-day lives. At the same time we have the sympathetic system, which is equally important, and it's responsible for maintaining our survival. So it's triggered or turned on by threat. That could be threat that we perceive from our environment like our kid's screaming or emails or traffic or it could be actual threat, which is something that literally actually is threatening to our survival. So lack of food, lack of air, lack of water, lack of shelter, presence of a predator, things of that nature.

What happens in chronic stress is that the sympathetic nervous system is turned on all the time, and that is fine in a short-term stress where we need to get away from a saber tooth tiger or we need to find water. You want all of your energy, all of our energy, to go to our skeletal muscles and our heart and to our brains and to energy conservation mode where we're using energy as little as possible and as effectively as possible to get us to a survival situation.

The problem is that when we perceive threat all the time what happens is our sympathetic fight or flight system gets all the energy and all the resources and then those resources end up not going back to the recovery system, which is critical for regenerating and rejuvenating us and bringing us back to a full sort of repleted rested state. Part of when we talk about managing stress is not just about improving one or the other nervous system, it's really about achieving balance between the two.

Heather Sandison, ND: An appropriate response to the situation at hand.

Dave Rabin, MD, PhD: Right, so a measured response, so it's a response that is not necessarily the first response, it's not necessarily the last response, but it's something in the middle where something happens, and we take a moment to reflect in that moment. Is this something that is actually threatening my survival right now? Is this threatening my physical survival, my physical safety? Is it threatening my list off the other kinds of safety, emotional safety, mental safety, even financial and legal safety are things to consider these days that affect us and that we don't often consider. If something is an actual threat to our safety in that moment, then it does actually warrant a turning on of that fight or flight response. That's really important to take energy away from digestion, reproduction, because you don't want to be worried about doing those things when you're running from a lion.

That said, we're rarely running from lions these days. It's very important for us to make sure that when our body, which doesn't know the difference between a lion and traffic, we recognize and remind our bodies by doing things like deep breathing, soothing touch, meditation, yoga exercise, all the things that sort of help to remind us that we're safe and that we're able to enter a recovery state. Those activities help to rebalance the nervous system reminding us that we're not actually under threat right now because we're safe enough to focus on those activities, and that over time helps balance the nervous system and helps us to cope with stress in a healthier way.

Learning to Cope with Stress

Heather Sandison, ND: Can we learn to be more stressed or to be more relaxed? There are people that I see certainly as a clinician, I'll see patients who are maybe going through very similar stressful experiences, going through divorce or losing a loved one, and one of them not necessarily thrives through it, but definitely takes it in stride, and it doesn't seem to affect them as deeply as another person. What's the difference between those two people maybe going through a similar stressful experience, but having very different responses?

Dave Rabin, MD, PhD: Right. That's a great observation. That's actually something that seeing what you just described and these differences in people and differences between the way I personally cope with stress and the way people around me cope with stress, really drove me to try to understand this pathway better and to understand why do these differences exist between us.

There's a couple of different reasons. I think as you were saying or as you alluded to earlier, there is a practice makes perfect pathway, and that's the fundamental way that the nervous system works, and this was actually discovered by amongst others Eric Kandel who won the Nobel Prize in 2002 for discovering how we actually form memories in the brain. It turns out that the way that we form memories in the brain is actually no different than the way that... or very minimally different than the way that 300 million-year-old sea snails form memories, which only have three neurons.

We don't actually necessarily need to have all of this complex brain stuff going on to understand how we remember and how we form meaning from our environment. What's interesting is that even in these ancient sea snails and actually all animals in between have the ability to recognize what is threat to their survival and what is safe. Then that trains the nervous system over time to strengthen pathways down a line of threat if they're surrounded by threatening things all the time to train to respond to threat more effectively but also more frequently and to be more sensitive to threatening stimuli, which is kind of what we see in adults or children with PTSD. Then there's also the opposite, which is training to respond to positive stimuli. So the more that we train ourselves to practice positive coping strategies.

As an example one of the ones that I use the most and I find is most effective for myself and for my clients is the practice of gratitude. When we feel bad, sad, angry, frustrated, annoyed, part of what makes those feelings so uncomfortable is not just feeling it, it's feeling ashamed at the same time for feeling those feelings. If we accept that those feelings are there for a reason, and if they're telling us something that we're supposed to be doing in that moment to resolve that feeling or get to the bottom of it so we don't feel that way anymore, then that is a much more resilient way of coping and a way that leads to recovery and growth more effectively than shaming ourselves or feeling guilty about feeling that feeling.

If we feel guilty or shameful about being angry, then what happens is we turn the anger inward on ourselves. We turn the guilt, we turn the negative feelings, the sadness, inward on ourselves, and then that results in this constant chronic stress response that we carry with us, which we effectively in some ways are practicing creating. And the more we practice it, the stronger the neural networks form around those feelings of shame and guilt and anger towards ourselves, but also anger towards other in our lives, and the anger never really subsides, it just continues or it grows.

So the alternative for that would be a thought strategy like, "I feel angry," so you acknowledge the anger, and you say, "Okay, I feel angry right now." We can say, "Why me? Why am I angry? Why is this happening?" That's the old path. And then the alternative would be saying something like, "I'm grateful for feeling angry right now because this anger is trying to tell me something about what's going on right now in my life that I need to address." Then that opportunity becomes instead an opportunity for shaming yourself or feeling guilty about the emotion. It becomes an opportunity to learn from the emotion and to grow from it, and then we become stronger as we understand how to self-manage those feelings more effectively on a path of growth rather than a path of self-shaming or self-guilt or self-sabotage. There's lots of ways to describe it. I think we see this all the time with our clients, and it's something that we constantly work with them to try to overcome, and it's something that we can all overcome.

That's the hope of this is that what I think Eric Kandel really showed is that any of us can train our brains and our bodies to overcome stress, to overcome trauma and to really rebalance ourselves in an effective way, but we have to believe that we can do it, and then we have to use the tools that we have available to us including our colleagues and our friends or resources, our personal thought resources, ourselves. We have to use all our breath. We have to start to use all those things and practice those things, and over time we learn to cope more effectively, Apollo being the tool that can help assist with that for people who are struggling.

Inheriting a Predisposition to Stress

Heather Sandison, ND: We're talking about what people can do, the personal responsibility or the personal ability I would say is very hopeful. There's this ability to change the course of your life or the way that you think through these past episodes of trauma, but also I've heard you talk about inherited trauma or how maybe our ancestors and what they experienced might be affecting our DNA or the way that we might experience the world. Without our having to have experienced trauma in our lives or even having had those habitual thought patterns, even having them be created yet, we could've just come into the world and have some degree of PTSD. Is that right? Did I understand that correctly when I heard you speak about that?

Dave Rabin, MD, PhD: I think what we're talking about is a predisposition. Predisposition is not a guarantee. It's an increased likelihood of experiencing symptoms of a particular kind, and in the case of what we're talking about, trauma, one of the ways that those symptoms are experienced is PTSD, which is hypervigilance, never feeling safe, always looking around and not feeling comfortable in your own skin or in your own environment, nightmares, flashbacks, things of that nature, insomnia. Then that leads to and is often frequently accompanied by low mood, chronic pain, all of these other things that go along with that, poor focus and attention, poor emotion regulation, et cetera. I think what we're describing is a pattern of behavior that is a coping strategy that sometimes we are taught and other times it's really a combination of the genetic makeup and the epigenetic makeup. What it seems that the data is showing now for those who don't know is that epigenetic, which means on the DNA, it's the markings on the DNA that tell skin cells to be skin and brain cells to be brain. Even though these cells all have the same code in them, they act differently.

Epigenetics help the cells to determine what the functioning of them is, and how to express certain stress response proteins at different times or more response proteins, and so the epigenetic inherited stress predisposition that you're alluding to is something that there's been an enormous amount of evidence for over the last three or four decades that has shown that or at least very, very strongly suggested that if we are traumatized or one member of a family is traumatized, and that member of a family has children, and they have grandchildren, and that trauma has never been resolved or processed in any way therapeutically to resolve it, then the patterns that affect the expression of stress and reward response genes, one example being cortisol, which we're all familiar with, a very powerful stress management hormone, is our change.

The expression patterns of those hormones are changed over the generation to which make it more likely that if our children... If we were traumatized, and we didn't deal with our trauma, and then our children are exposed to stress, they're more likely to wind up coping with that stress in a way that leads to an increased risk of PTSD, depression, anxiety, maybe hoarding, maybe metabolic disorder and diabetes and obesity also fall into this category.

It's not guaranteed by any means. The genetics and the epigenetics are not a guarantee, but what I think the epigenetics show is hope that we actually... It confirms the scientific basis for hope that we can ratify and modify the way that we are, that there's no permanent... It's almost never the case there's permanent imbalances from what we can tell of hormones or neurotransmitters in our brains. Even when we're feeling our worst ever, that is only typically a reflection of that state in that moment. If we are to engage positive coping strategies or to change the way that we think about ourselves and change the way we think about our situation and change our actions, and the way we process emotions, all of that leads to reversals. It seems to be likely and the evidence suggesting that will lead to reversals of these epigenetic coding on stress and reward response genes that ultimately could be passed on over time.

Again, this is not yet known for sure. I'm working with a number of folks to study this phenomenon, and we will have answers for you over the next few years as the results come back. I think that we do know that trauma does cause these changes, and we know that those changes can increase the risk of these mental illnesses. For us, it's about coming up with all the ways that we can to understand how to help people modify that, not feel stuck.

How Role Models Shape How We Handle Stress

Heather Sandison, ND: So, Dave, this is so fascinating, of course, to you and I both. I want to get into the therapeutics and what we can do about it, but before that I want to just fully understand. It sounds to me like there's basically three potential ways that you can end up with, I'm just going to call it PTSD. Basically it's this behavioral response that maybe doesn't fully serve you. It doesn't serve us. One could be potentially this inherited epigenetics. Another could be that you personally experienced some degree of trauma, maybe early in life or at any point, I guess. Then third I think I heard you say that you could learn this behavior, so maybe it's like your mother was hypervigilant. It might not necessarily be in the epigenetics or in the DNA, but that just watching your mother be hypervigilant every day, you would learn to be hypervigilant yourself. Is that right? Is there any other way that we could end up in this subpar response pattern?

Dave Rabin, MD, PhD: I think those three ways pretty much sum it up. I think the one step... I think it's very important to acknowledge that it's not typically just one of those three, it's usually a combination. It's usually a combination of to some extent all of those things and in most people that we see. We don't live our lives in vacuums, we're constantly exposed to role models all the time, many of whom are not coping with stress in a healthy way.

I think we can all think of somebody or multiple people in our lives who had an influence on us growing up or even now where we look at that person as a role model, but they may not be the best at coping with stress in a healthy way. Society also does not necessarily encourage... Our society and Western society does not necessarily encourage or make available the most healthy coping strategies. Alcohol as an example is not a healthy coping strategy, but it's readily available to everyone, same with cigarettes, same with prescriptions, sedatives and narcotics and stimulants. These numb us or distract us from the problem, but they don't actually solve the problem. It's kind of like putting a Band-Aid on a broken leg, but it's still broken. It still becomes gangrenous and festers and eventually falls off if it is not managed, and it could kill you if you don't take care of it properly. But we still adopt that methodology for treatment of these things in Western medicine when it comes to emotional and mental illnesses.

I think the short answer to your question is, yes, it is those three as the major source, but role models is particularly interesting because it's a broad category, so it could be we think of role models as people who are right next to us in the immediate... People who we're having conversations with or our teachers or our families or siblings and things like that, friends. We forget that TV, radio and pop culture, all of these things also influence us as role models are present as a role model.

All of these people are role models. When they role model for us in a way that is not constructive or not consistent with a sustainable, resilient lifestyle, and we take that to heart and don't process it as, "Is this something I should be doing or not? Is this the right way to approach this or not?" We don't question it, and we just integrate it into our sense of self, then that's when we start to integrate these tools that aren't necessarily serving us because they seem helpful in the moment as you said earlier.

Then the trick with psychotherapy, which is relevant to all of us, not just people who are mentally ill, but the whole point of psychotherapy in general and psychology is to just take a step back for all of us and understand what are the things, the tools, the coping strategies that I've been doing up until now that have been serving me and which ones haven't been serving me? And then to take the ones that haven't been serving us and understand why we cannot attach to them anymore or detach from them. We don't need them anymore because we have now with all of our collective wisdom, of all of these years and all of this time, we can start to understand, hey, maybe there's something better that I could be doing to respond to this, which is different than what I learned when I was five, six, seven, ten years old, et cetera.

Preventing PTSD from the COVID Crisis

Heather Sandison, ND: Absolutely. Also, society as you were describing these ways that we can be influenced, a lot of us walk around using busy as a badge of honor. "I'm busier than you," or "I've got more hats that I'm wearing than you." It's almost this competition to be accomplishing more or to be doing more, and then we're rewarded for that. That doesn't always serve us. Right? But it's certainly the way things are set up.

Dave Rabin, MD, PhD: Right.

Heather Sandison, ND: Now, we are recording this conversation-

Dave Rabin, MD, PhD: Perfect example.

Heather Sandison, ND: Right. I'm certainly influenced by that. We are recording this conversation in the context of the COVID crisis. We are deep in the middle of it, mid-April, and a lot of us are stuck at home. This conversation is just perfect for that context because there is so much stress whether unfortunately people are losing loved ones, other people are experiencing the severe stress of being alone but in a hospital potentially on a ventilator, intubated, sedated, and not having their families able to come in and check on them. Then the majority of us are just stuck at home and have been affected potentially traumatically because of the loss of a job or the loss of meaning, the loss of being able to get out and see friends and family.

I want to go deep into your expertise, which is what to do about this. I believe that there's going to be a huge surge in people that have PTSD because of this crisis. After crises like wars and things in the past we know that this happens. Now here we are armed with more tools than we were after Vietnam or World War II. What can we do?

Dave Rabin, MD, PhD: That's a great question. Again, I just want to start by saying this is a time in history that we have not faced in a long time, particularly in the last seems like now 50 to 70 years. This is pretty much unprecedented for us, and I think it is scary for everyone. There's a lot of misinformation out there. There's a lot of poor reporting. There's also a lot of stressful talk that is very threatening and scary. It's scary for all of us. It's scary for us as health providers. I think one of the things that we're going to see is as you said the threat of things like this trauma affecting that way that we deliver healthcare. One of the things that's very tricky for us as healthcare providers is that we have a duty to be on the front lines helping people. We have a duty to in whatever way we can to provide our services to people who are suffering and ill.

At this point, a lot of my colleagues do not have adequate protective equipment. They do not have adequate safety guards for themselves to ensure that they can manage their stress responses and deliver care on a continuous basis to people without worrying about putting their own mental, physical and emotional health in jeopardy. I think we're starting to see that already as you said with the emotional health and the mental health where people are not sleeping as well, particularly healthcare providers, but all of us. We're not sleeping as well. We're not taking necessarily as good care of ourselves. Alcohol consumption is up. Drug consumption in a lot of places is up. This is a problem.

This is the exact problem that in a lot of ways has led to the situation that we're in right now, and I think if we are not able to take a step back and recognize what has happened that has built up to this current situation we're in and not continue down that path again, then we're missing the boat here.

How Heart Rate Variability Impacts Stress and Wellbeing

Dave Rabin, MD, PhD: One example that I think is really important to talk about is this idea of heart rate variability. Heart rate variability is the rate of change of the heartbeat over time, and going back to what we were originally talking about when we first started this conversation about the sympathetic and parasympathetic nervous system, heart rate variability has really come to the forefront in the last 40 years as being the most important biomarker for tracking health and recovery on a regular basis, and not just health and recovery, but resilience.

What heart rate variability correlates with is having good resilience, good ability to bounce back from stress meaning that when the stress or the threat is gone, our bodies very quickly decrease their heart rate, decrease their blood pressure, decrease their breath rate, decrease their sweat and increase reproductive activity, increase digestion, rest, because we recognize that we're safe and we do that quickly because we recognize the threat is gone. People who have PTSD, depression, anxiety, chronic pain, a number of other conditions, many of these folks it's now been well documented these people have low heart rate variability and amongst the lowest that we see in clinical settings.

That is problematic because what it's telling us is... It's also incredibly helpful as clinicians and also to help our patients because that's telling us that there's imbalance in the sympathetic and parasympathetic system. People who have high stress response activity, their heart rate is up higher most of the time, and their heart rate variability is lower most of the time. They respond to stress, and they bounce back from stress more slowly, and they are less likely to survive when they are threatened. The opposite is true for people who have high heart rate variability, people whose heart rate variability is in the 80s to 160s to 200s, which does happen in people who are well trained, and we don't know what the peak limit is.

What You Can Do Now to Minimize the Impact of Stress

Dave Rabin, MD, PhD: Whereas people who have severe treatment resistant mental illness or who are chronically ill, these people tend to have heart rate variability in the 40s and below. So what we're really starting to see is we can actually predict who is more likely to suffer the severe consequences of illnesses, who's more likely to be resilient, now what activities actually improve that. Meditation, mindfulness, yoga, deep breathing and breath work, lots of different breath work techniques, soothing human touch or touch from a loved one or an animal, and doing things that generally take good care of our physical and mental and emotional health. All of these things tend to improve heart rate variability.

Heather Sandison, ND: Exercise?

Dave Rabin, MD, PhD: Psychedelic medicines... Exercise is a great one, however, not over training. Not training to the point of exhaustion all the time, but training to the point where it is a healthy amount of training, which we is very personal to each person and identifying what level of training we need to reach so that we feel good but we also feel rested the next day, and we are not overdoing it because that increases our risk of injury. Obviously, there are caveats in all these things, and you can overdo anything, but the point is that if you're tracking heart rate variability it's a really great way to understand how you can trend up and track your resilience, which we've never been able to do before.

So that's a really powerful tool. Doing these kinds of activities at home is something that we really need to start focusing on right now. If we drink, alcohol decreases heart rate variability, just sort of going back to what we were saying before.

Heather Sandison, ND: There's a handful of things that people can be doing right now at home, and you specialize in heart rate variability, and you have some really unique interventions for that, psychedelics and the Apollo device. I want to get deep into those, but before we go there, I just want to cover the bases of what people can be doing at home right now. It sounds like some of these fundamental basics like getting enough exercise, the right amount of exercise for you. I would imagine sleep, so getting enough rest and probably at the right times in the night, going to bed before midnight, that kind of thing.

I'm curious if food, if diet has any relationship with heart rate variability. I'm not aware, but-

Dave Rabin, MD, PhD: For sure.

Heather Sandison, ND: ... you are the expert in this. Can you just talk through... And certainly meditation, yoga, things that would be easy to do if you're trapped at home right now, and certainly if you're a healthcare provider. Thank you for acknowledging them. The people on the front lines of this, the people that work in the grocery stores that are first responders, people that are in those essential businesses. Thank you to every one of you. Hopefully, some of these tools can be relevant not only for those of us stuck at home but for those of us who have even higher stress levels because of their proximity to this.

Dave Rabin, MD, PhD: Right.

Heather Sandison, ND: Those things that are easy to do at home, can you just break them down?

Dave Rabin, MD, PhD: Yeah, absolutely. The other thing I'll say even leading into that is that when we talk about these activities that boost heart rate variability the reason why these activities are important is because we have control over these activities. We can do them almost any time and are free, and they improve our sense of agency, autonomy, empowerment, our ability to control our lives and to feel in control of our lives. Why is that important? Well, that's important because one of the single biggest sources of anxiety in all of our lives is simply trying to control things that we have no control over in our lives. When you spend time thinking about all of the things we try to wrap our arms around that we can't control like the way other people drive or the way that somebody's talking to us or any number of other things, the way other people are acting, et cetera, thinking about all those things literally is increasing our fight or flight response in our bodies. It's increasing our sense of anxiety and feeling overwhelmed, and that is similarly decreasing our heart rate variability because our bodies don't know to not perceive that as threat.

So the reason why these techniques like breath work, which is one of the first ones I think most importantly to start with, the reason why breath work is so powerfully important to building our resilience and our recovery is because you can do it at any time, and it's free, and it works on a very powerful subconscious level. As we take a deep breath in, and we've all probably done this for the most part when we're stressed out or when we're not, is we take a moment, and we sit and just try to focus on our breath, and we take that breath into our bodies, and then we let it out and then hopefully we repeat that a couple of times.

What we find is that in the body the response to breath is almost immediate, and the reason why it's almost immediate is because as the breath comes into our bodies and our minds start to pay attention to the feeling of air coming into our bodies. Our bodies and our minds subconsciously typically completely beneath our level of average awareness says that if I have time to pay attention to my breath right now and the feeling of my breath right now, then I'm not running from a lion. I must be safe enough to be able to take the time out to pay attention to my breath.

It's the same when somebody you like touches you in a nice way or when you touch yourself. Putting pressure on your chest can increase parasympathetic activity as well and help improve recovery and sense of calm. Rubbing your hands in certain ways can do the same thing. We talk about a lot of these techniques actually on the Apollo website if anybody's interested. But the point is that doing any of these things, touch, breath work, self-touch or touch from a loved one, yoga, regular exercise, diet and making sure that we have all the nutritional things that we need to be able to feed our bodies good fuel. Nutrition is the fuel, so that's fundamental and important, and having also fuel that's healthy as much as possible, so avoiding things that have heavy levels of pesticides or herbicides or potentially GMOs might be causing some of these issues for us.

Starting to try to have as much natural stuff coming into the body and then natural outlets for the body to get that restless energy out is critical because that reinforces through practice makes perfect like we were talking about earlier through the Eric Kandel memory model that training our bodies is like training our muscles in the gym to get stronger and it strengthens the neural connections not only between our brains and our muscles but also between our brains and other parts of our brains. It helps make all of this easier, and it helps make us feel more in control over time. Sleep though I want to end on because that is the single most important way to boost heart rate variability. I don't think we found anything more important natural than sleep because that's when our bodies do most of our recovery and our minds do most of our recovery when we sleep.

Focusing on getting good sleep is important and critically important to recovering. That said, if we don't feel safe, it's very difficult for us to allow ourselves to sleep. It's difficult to allow ourselves to heal. That's why the breath work comes back in full circle. If you're having trouble sleeping, we have breath techniques on our website and lots of other people talk about these. Apollo is another tool to help. That can help ease the body by providing safety signals to the body through the skin or through breathing techniques or self-touch to help guide the body or nudge the body into a more safe state, which brings the mind along with it, and then that allows us to transition into more recovery states more quickly.

About the Apollo Neuro Wearable Device

Heather Sandison, ND: Tell us about Apollo and the research that you've done. How does Apollo work? How have you determined that it does work?

Dave Rabin, MD, PhD: Originally we were... I'm a psychiatrist and a neuroscientist, and I was working with a lot of people who have treatment resistant posttraumatic stress disorder, depression, anxiety and substance abuse disorders. What I realized from working with my clients and also reading an enormous amount of literature on these topics was that overwhelmingly what we're seeing in the body is that our clients don't feel safe, and their nervous systems show it. They show low heart rate variability as one sign of not feeling safe. They show high resting heart rate. They sweat easily. They respond to stress when there's no stress around. All of these things are indicators that they don't feel safe.

When do they actually get better or when do they feel better? Well, even people who are the most sick, the most treatment resistant, they feel better when somebody's having an empathic conversation with them and actually listening to them and looking at them in the eye and making them feel like they can talk about whatever it is that's on their mind in a nonjudgmental accepting way. That is how we as humans for free can provide safety to one another very quickly, and it's extremely powerful.

Soothing touch, hugs, holding hands, soothing music, all of these things are ways that we can rapidly convey a sense of safety to one another, but the problem is all these things require somebody else to be there. What we found was... I'm also an MDMA trained psychotherapist and a ketamine trained psychotherapist. Any psychedelic medicines work in the same way that they have these incredibly powerful healing effects on people that can literally transform somebody in just a few sessions who's been ill for over a decade to somebody who is no longer having significant symptoms simply through accelerating the safety pathway we've been talking away.

So having seen all those patterns, I said all right safety is critically important here, and it is rooted all the way down evolutionarily in our nervous systems into Eric Kandel's work and all these things that we've been talking about. I thought, "Well, would it be possible to figure out how the nervous system responds to safety signals from the environment, what it does to the body, what it does to change our heart rate and our breathing, which we found actually changes pretty reliably to a breath pattern of about five to seven breaths per minute, and this has been shown through biofeedback, and that's kind of like the signature that the body is starting to feel safe is when it enters the five to seven breaths per minute pattern.

And then we said, "Okay, well, what if we activate the nervous system through the sense of touch through the skin, could we induce the same state of five to seven breaths per minute state in a person where their heart rates start to come down, their breath rate starts to come down, even under very intense stressful situations like intense computer tasks, math tasks, physical tasks, all these things. Can we show that the body is calming down, and will that result in improved performance and improve the way that people feel?

We did these studies at the University of Pittsburgh. We started with pilots, and then we expanded out into a double blind randomized placebo controlled crossover study, which was wrapped up in 2017, and we found that when we exposed people to these very specific patterns of sound that are basically bass frequencies that kind of feel an ocean wave or a cat purring on your body or holding a loved one that the body feels these patterns, it recognizes the patterns. Without you having to do anything it knows that these patterns indicate or are sending a signal that's safe enough to calm down.

In this study we showed that within three minutes under stress the first study in the cognitive test with three minutes under stress we were able to improve cognitive performance up to 25%, and that improvement in cognitive performance correlated directly in improvements in heart rate variability. There's never been a technology that has shown that you can improve heart rate variability within three minutes under stress ever and that that directly correlates with academic or cognitive performance. Now we've actually had other groups show that this is actually reflective of enhanced physical performance as well.

The more that we have been testing this, now we've tested it in thousands of people in the real world because lab studies are great, but if you don't show it in the real world, then are you actually inducing a real benefit in people's lives? So we've done the real world studies since then and a number of other clinical trials, and the results are continuously consistent showing that people are improving their heart rate variability when they use Apollo, yet they're also improving the way they feel. They're improving the way that they sleep, and we see this tracked over time using wearable biometrics, and we see people who are very, very severely ill, people who have disorders that relate to low heart rate variability like PTSD, depression, anxiety. We see these people having dramatic benefit from Apollo where they say, "I don't remember the last time I felt safe before I put this on."

They're able to sleep, at least they're telling us that they're sleeping better and they're functioning better in their day-to-day lives, and they're not requiring as much medicine, which is a huge goal for us because Apollo was originally... Now, we all use it. It's used by tons of people. Most people who use it aren't ill because it's an incredible tool for performance and for stress management resilience in general. But originally we developed this to treat people who had no other treatments available to them, kids, people with treatment resistant mental illnesses, pregnant women, geriatric patients with very severe illnesses.

The fact that we're able to see this consistency across the board was extremely promising, and it's something very rarely seen in science, and I think it's really hopeful to us because it shows we did our homework right. We really did a lot of research behind this before we invested our lives into it, and we found that without a doubt we're on the right track. Is it perfect yet? No. But over time now that we're on the right track, we know that as we continue to develop the technology, it will get better and better and better, and the results we're seeing are really incredible and humbling.

Heather Sandison, ND: This is exciting. We can get a watch or did I understand correctly that we could also get a cat, and that would make us smarter? That was my big takeaway. I need a cat. I'm just teasing.

Dave Rabin, MD, PhD: Yeah.

Heather Sandison, ND: This is phenomenally exciting. There's this quite simple way wearing this watch. Do you wear it 24 hours a day or just at night? It's changing sleep. It's changing cognitive function. Literally, you could be smarter if you feel like you're safer, and that makes a ton of sense. Right?

Dave Rabin, MD, PhD: Right.

Heather Sandison, ND: You just open up the bandwidth to take in information, to process information. So better sleep, better cognition, better resilience to anything that's going on, to any stressor. So hugely, hugely helpful.

Describe the process. Is this cumbersome? Is it heavy? Is it expensive? What's the process of doing this?

Dave Rabin, MD, PhD: I can show you. I think the core is safety. If having a cat with you all the time makes you feel safe, then that's great, but that's just not a solution that everybody has available to them.

Heather Sandison, ND: And it comes with a litter box.

Dave Rabin, MD, PhD: Right, right. And all of these things. A lot of people what we see the most common way that's similar to this is music. People have music with them. They listen to headphones all the time. That music keeps them calm. It keeps them in the zone, in what we call flow. But we can't listen to music when we're having a conversation with somebody else. We can't listen to music when we're giving a talk on stage or performing surgery or whatever it might be.

Apollo is really our way of providing a tool that doesn't require you to do anything else and kind of wear it in the background. I have one on here right now. I wear it most of the time on my ankle actually, but people wear it on their wrist or their ankle. It's completely optional. There's two buttons, I think you could see right here, that can increase or decrease the intensity and can also turn off or on the vibration patterns without you having to go back to your phone. It's a technology that can work completely independently of your SmartPhone, but your SmartPhone can be used to track data and also to change settings and set up more interesting, more complicated patterns and things like that over time.

Ultimately, it is very simple to use. We have seven settings in the app. The settings range from energy and wake up, which is the most stimulating. And that people commonly use in place of coffee or energy drinks, and it feels a lot like caffeine. In the way of social and open, which a lot of people say actually feels kind of like MDNA, which is this very safe socially friendly, open, not in your own head, not judging yourself when you're engaging with others, a very nice clear energy that's very friendly and social.

Then there's clear and focused, which is more like amphetamines or stimulants. It's like a deep, intense focus. We really designed these to kind of feel like medicines that we know because if you can make them feel something that's familiar, then people get that more easily. Those are the most wakeful settings. Then there's the recovery frequency, rebuild and recover, which is kind of in the middle. This frequency is great for immediately post-physical or mental stress. It just helps the heart rate come down quickly. It helps the blood pressure come down quickly, the breathing rate come down quickly, and it helps us come back to homeostasis and balance more quickly after a stressor happens.

Then there's the much more common settings, which are more used in the end of the day. So the ones used in the end of the day for most people or around the evening, nighttime, are meditation and mindfulness, which is great for winding down and/or what we call calm flow. That's one of my favorites. Then there's relax and recharge, which is deep relaxation bordering on sleepiness. A lot of people say that kind of feels like cannabis indica. Then there's sleep and renew, which is what it says, which is helping you decrease the time it takes you to fall asleep when you get into bed and just rapidly accelerates your ability to enter restful, calm sleepy state. We've seen a lot of people in the wild send us back their data showing that they're within just a week or two of using Apollo they're having great improvements to their REM sleep amount that they're getting, their deep sleep that they're getting, and their HRV over time as they sleep, which is truly promising.

Heather Sandison, ND: I can think of a handful of patients that could really benefit from this maybe every single one of them. So it's a wearable device. What's different about Apollo to me it sounds like versus an Apple watch or even any sort of FitBit, that's just collecting information and then giving you back the data in a way that's easy to see. But what Apollo's doing is it's actually using... There's an input, so your body is getting data from the device or information from the device. How does that come? Is it in frequencies? Is it electrical? What is it that's going into our bodies? Is there a side effect?

You talked about comparing it to a lot of different substances like MDMA or cannabis or some of the amphetamines. Are there side effects to what Apollo is putting into us?

Dave Rabin, MD, PhD: That's a great question. I apologize if I didn't mention it earlier. Apollo is side effect free. We designed it to... I'm an addiction psychiatrist. It's most of my work. We designed it to be nonaddictive and not of any contraindications, and so all the frequency settings that we use are frequencies that have been studied in the literature. Half the intensity levels that we use, they've never been found to have any side effects in people, which was great. That's been a huge, huge success for us. The other side of it is what do they feel like is they feel like... It's sound waves. If you've ever stood next to a subwoofer or been to a live concert, we are frequently used to hearing sound and hearing music that makes us feel differently, but you don't have to actually hear music for it to change the way you feel. You actually just have to feel it.

Our skin is a listening organ just like the ears. What we're actually doing, and I think the best way to describe it for people who haven't tried it before, is based on the neuroscience of music, neuroscience of touch and the neuroscience of the way the body enters meditative state and enters recovery states and manages stress states, we have developed basically songs that I composed using vibration that are bass frequencies in music. They're like subwoofer range frequencies in music that are songs that I composed for your skin as a listening organ rather than your ears.

Therapeutic Use of Psychedelics 

Heather Sandison, ND: Fascinating. This is a really, really unique offering. Another unique thing that you describe a lot is psychedelics. You're a psychiatrist, so you're very familiar with substances and the effect that they have on our brain. Psychedelics are really in a class of their own. Can you describe why and how that connects with this theory of safety being so important in our ability to change heart rate variability and be resilient.

Dave Rabin, MD, PhD: Psychedelics are in a class of their own. That's for sure. Part of the reason why psychedelic medicine or psychedelic substances are in this class is because they have a different path of treatment than what we can refer to as maybe standard Western treatment options. When we think of standard Western medicine treatment options, and let's just focus on mental illness for now, just to make it simple, the way that we are taught and the way that we prescribe medicine as many people are familiar as psychiatrists is we typically prescribe one or multiple medicines to be taken one or multiple times a day every day for an ongoing or indefinite period of time.

We're told to actually tell the patient or our client the statistics, which is that if this medicine helps you and you discontinue use, you are likely to have a relapse, and then you're more likely to have more relapses every time you relapse. That is not a hopeful story as you can imagine. What we really see unfortunately is that that story that we're telling people in a lot of ways fosters what we call chemical dependence, which is really what we're trying to avoid in a lot of cases in the first place.

What is interesting to me the most about psychedelic medicines and sort of what really makes them different, why are they actually in a class of their own that really makes them worth investigating further is that these medicines work in one to three to six doses. They don't require daily dosing, and they don't require you to take one or multiple medicines one or multiple times a day to get benefit consistently. They actually work in the opposite way. You take one or three or six or ten doses over the course of a couple years, and then these dosing experiences combined with an intensive psychotherapy typically is very important.

It's the psychotherapy before and after that helps guide a person about how to learn from their psychedelic experience.

The Importance of Setting with Psychedelic Use

Heather Sandison, ND: The idea and setting.

Dave Rabin, MD, PhD: Right. That setting is really where the safety comes in. The psychedelic medicines are fantastic, but they are equally as likely to traumatize somebody as they are to heal somebody if they're used in an unsafe way. I think a lot of people don't recognize that risk, and then that puts them inherently at risk. If we recognize that psychedelic medicines are incredibly powerful and they have the power to do as much harm as they do good, then it reminds us to constantly focus on using them in a safe and respectful way and to really be mindful of setting before we go into these experiences and intention, the intention that we bring into the experience.

What do we intend to get out of this experience? Are we intending to use this psilocybin mushroom or this MDMA as an escape from my reality, which is not necessarily ever the best way to use these medicines? Or am I using intentionally this medicine to help me figure out something about my life that I can do better? Right? Not to escape.

Heather Sandison, ND: Maybe change your reality.

Dave Rabin, MD, PhD: Exactly. Or change the way that we see our reality.

Heather Sandison, ND: Your perception of your reality. Right.

Dave Rabin, MD, PhD: Right.

MDMA, Ketamine and Psilocybin in a Clinical Setting

Heather Sandison, ND: There's a handful of psychedelics out there. You mentioned MDMA and ketamine, psilocybin, ayahuasca, the list goes on and on. In your clinical experience, do you have favorites or do you have ones that tend to come up for different circumstances, maybe addiction versus PTSD versus the whole depression?

Dave Rabin, MD, PhD: Sure. Well, I think right now we're a little bit limited legally in this situation. What my favorites might be based on the science of how these medicines work and what I've seen in the clinical trials is not necessarily consistent with what we're able to offer clients because legally these medicines are still not scheduled in a way by the DEA that is conducive to us being able to use them in a way that we would like to.

For instance, MDMA and psilocybin are incredibly powerful medicines. In some places MDMA is now decriminalized, but it is technically still a DEA schedule one drug. As a physician who's licensed by the federal government by these federal boards that be, I am unable to provide MDMA and psilocybin treatment outside of a clinical trial to patients, so it makes it a little bit tricky.

But they're incredibly powerful, and there are clinical trials available to access these medicines. I would say that the medicine of choice right now is ketamine. The reason is because ketamine is legal in almost every state. The total experience for ketamine only lasts about 30 to 60 minutes of the actual peak altered state experience, and then there's some afterward time for recovery. But, in general you can pretty much wrap up one ketamine therapeutic encounter within two to three hours whereas psilocybin and MDMA could take eight to ten hours and sometimes people have to sleep over overnight, so that increases the amount of demand on the care provider. The whole clinical experience becomes more complicated and more expensive.

To give you an idea, we can do a ketamine treatment course for something like $3000 in somebody, maybe a little more depending on how complex it is and how many sessions are required. But MDMA is closer to $14,000. Just in terms of the amount of time and the access... And MDMA is also not yet reimbursed by insurance, ketamine is to some extent. So there are ways that we can provide these services now. Ketamine is an incredible medicine, and it's been around for a long time. It's been studied for a long time in this way.

One of the founders of ketamine to assist with psychotherapy is Dr. Phil Wilson for anybody who wants to look him up. He's worked with MAPS for a very long time, and he also helped coauthor the MDMA assisted psychotherapy protocol, so they're very similar. It's very incredible treatment but is actually interestingly enough, which you may not know about, and I'm sure many of your listeners may not know about, ketamine is going to be offered very shortly, if not already as you're watching this podcast, via telepsych, telemedicine.

So that means that if you are in a state where a pharmacy will synthesize an oral ketamine formulation, which we can write for to that pharmacy, then we can walk you through ketamine assisted psychotherapy experiences for trauma and depression at home.

Heather Sandison, ND: Wow.

Dave Rabin, MD, PhD: This is going to be something that is going to revolutionize the way that we provide care to people particularly at a time like this where there's a lot more trauma going around.

Psychedelic Assisted Therapy via Telemedicine 

Heather Sandison, ND: Wow. Yeah, that may be one of the more transformational things that comes out of this is how medicine is changing, how we deliver medicine is changing with this with it being necessary to not be in the same room and share germs. What are the potentials for getting access to people who aren't in the same room with you? I didn't even realize that you could do oral ketamine. I thought all of it was IM or IV. Yeah, this is definitely news.

Now, there is a potential risk that goes up? Because I guess this whole idea of safety, we've all seen a movie or something where there's a bad trip. And this idea of safety is so integral to what you're describing. So not being in the same room with someone who is experiencing ketamine, does that make it less safe?

Dave Rabin, MD, PhD: I think that it's ideal that we are together physically during the experience especially if somebody has never had one of these experiences before they can be really powerful and really new, unfamiliar. I think that lack of familiarity can be scary for people. That said, I can tell you that having worked with a lot of clinicians who have done this for a while, Phil being one of the main folks who is extraordinarily experienced in this area, they've come up with some incredible tools to manage that issue and to make people feel safe at home.

At first, I will admit that I was skeptical about what that would be like and how well that would work, but I think that what's interesting about all this is is really getting down to the core of why do we do psychotherapy. Why does psychotherapy benefit us? Why should we all do it not just those of us who are ill, but why would psychotherapy benefit all of us?

It benefits us because it empowers us to heal. It empowers us to allow and tell the parts of ourselves that are capable of feeling ourselves without anyone around to turn back on and for us to have belief in ourselves restored that we have the ability to do some things, to be in control of some things to heal ourselves or at least kickstart that process.

One of the things that's really interesting that's coming out of tele ketamine work, remote psychedelic work, is that we are empowering people to understand that they can do some of this stuff on their own more effectively and maintain and establish their own safety more effectively from the comfort of their home, and they don't have to come to an office. They don't have to rely on us for that safety. We can still help guide through Zoom, through these video conference apps, and at the same time we guide them towards their own empowerment.

Because if we can't make change in people's lives, it's one of the oldest teachings in psychology and psychiatry, you can lead a horse to water, but you can't make them drink. Right? We can't force people to change. If I can empower somebody to change, if I can help them understand why they want to make a difference in their lives, and then the core skillsets that they have already that they can use to do that, then it becomes an incredibly powerful healing experience. And we can mitigate almost any risk to the point where it's basically no more risky to do it at home with us on camera as it is to do it with us in person.

Heather Sandison, ND: Right.

Dave Rabin, MD, PhD: We always start with the doses very low to start [crosstalk 00:57:50].

Heather Sandison, ND: It doesn't have the risk of these long-term interventions like the benzos and amphetamines-

Dave Rabin, MD, PhD: Right.

Heather Sandison, ND: ... and antidepressants or the side effects. With the psychedelics, a lot of times what we're doing as I understand it is when you lead a person through a journey, there is this invitation to sort of lean into some of the traumatic experiences of their life and almost relive them so that they can reprocess and create a new perception of that, and so it is quite scary. There is a lot of fear of that leaning into what does this have to teach me versus that habitual this is totally threatening.

Can you talk through some of your clinical experience of that and what that might look like for someone?

Reprocessing Trauma through Therapeutic Use of Psychedelics 

Dave Rabin, MD, PhD: Yeah, that's a great question. I think that's something that a lot of us are often afraid of not just those of us who have an illness. A lot of us are sometimes afraid of going deep into ourselves and thinking about our vulnerabilities and our weaknesses and things we've done wrong or bad things that have happened to us. I think that that is really at the core of the work we're trying to do with people.

I was just talking to a colleague about this the other day who's a nurse who has been working in sexual health for a very long time. She has an incredible heart, and she is just incredible with her patients and just talking about the idea of what is the service we're really providing people. And that that service as caregivers what we're providing people is the space that's safe enough for them to feel nonjudged and accepted and listened to in a way that allows them to just feel comfortable starting to open up with their own vulnerability. Starting to be able to just see eye to eye with the parts of us that are vulnerable or that feel vulnerable, that feel uncomfortable, that feel weak or that feel shameful and allowing those to come to the surface so that they can be worked with in a way that maybe we haven't thought about working with them ever or maybe we thought about it years ago, but then kind of swept it under the rug because it wasn't the right time.

I think that part of the reason why this is all important to talk about is because part of the reason why people have bad experiences sometimes with psychedelic medicines is that they use it, and that psychedelic medicine in the environment at one point helps them facilitate a feeling of safety to the point where it allows some of the stuff to come up, but then they are not ready for that stuff to come up when it does come up. And so they don't know what to do with it. They don't have the support. And in a lot of cases that I've seen people end up retraumatizing themselves again, which defeats the whole purpose of that experience whereas what we're doing is we prepare the person in advance, usually with at least one session if not several where the person is adequately prepared and feels ready to tackle whatever it is that might come up not in a tackle like, "I'm going to destroy this part of myself," where it's a war. It's not a war.

It's that whatever comes up, they're ready to work with it gratefully, compassionately, accepting, non judging, the same things that we instill in our patients in the therapy experience. It helps them trust us. It is about helping them understand that they can trust themselves again enough to allow some of these parts of ourselves that were uncomfortable come to the surface so that they can be reworked and really just re-understood from a standpoint of safety right now, not a standpoint of fear when it happened in the past. Does that make sense?

Heather Sandison, ND: Yeah, it's so powerful, so, so powerful. Really transformative. Are there ways to do this without psychedelics? Psychedelics I think of them as sort of a catalyst. It's maybe a way to get there faster.

Dave Rabin, MD, PhD: Great. There are great benefits.

Other Powerful Tools for Mental Healing

Heather Sandison, ND: Yeah. What are other things that people can do to get the benefits of this sort of approach without the substance?

Dave Rabin, MD, PhD: First off I'll just say that in case I wasn't clear earlier all of the tools that we're talking about are catalyzed by psychedelic medicine when they're used in the right way, but ultimately all of these tools, all of these strategies that we're talking about are tools that myself and my colleagues use in our therapy sessions without medicine on a regular basis. All of this radical nonjudgment, radical self-acceptance, radical acceptance of others, empathic listening tools, all of those things that we use to help our clients feel safe in the office or wherever they are with us or whether it's over Zoom or Skype or whatever it may be, those tools are being used and should be relied on and practiced as a priority regardless of whether a psychedelic medicine is in play or not.

If a psychedelic medicine is in play, it's even more important to prioritize all of those things because people are in an altered state where you don't necessarily know what's going to come up in advance. Usually you have an idea, but you just don't know for sure. Oftentimes they don't even know what's going to come up. For us, it's critical to do that. I think the main thing is really just tying it together with safety practice. One of the things that we can do for each other right now is that we can provide empathic listening. We can provide soothing, nonsexual intimate touch with one another and to ourselves right now, and we deserve it.

We can be grateful for our breath and our ability to breathe right now, which brings us back into our bodies, back into the present moment. All of these techniques are focused on enhancing mindfulness, which is really about being present in the moment with whatever it is we're doing right now, and all of those things are safety based techniques.

And it starts with us. If we have people that we are close to that are struggling, being there for them as a listener, not waiting to speak but just being there as a listener making eye contact and really showing that person that you're really listening to what they're saying, and you're not thinking about what you have to say next. It's really just about being with them and holding that space. That is one of the most therapeutic things that we can do for each other on any basis that facilitates healing. Again, that in combination with intimate, nonsexual touch with intimate self-touch, we have a little spot on the inside of our ear right here that you probably can't see because you can't see the video that I'm on, but there's a little spot on the inside of the outer ear that can be pressed that actually increases parasympathetic tone.

All of these different strategies are ways for us to really just improve our sense of safety which allows that parasympathetic recovery, healing response that's in all of us, to turn back on. We all have the ability to do that at any time. So the more we practice those techniques, the easier it gets to be able to do that. And that's really what Apollo is is we understand how hard these techniques are to practice. Psychedelics are great. They're hard to access. They can be expensive. Deep breathing and meditation can take thousands of hours to become good at, but if you can put on something like Apollo, then you can have something that can get you into that mind state right away or almost right away that helps remind the body that we're capable of feeling that way. We're capable of feeling safe in these situations. And then when we realize that we're capable of feeling safe, we actually naturally start to try to achieve that on our own.

There's no dependency with the device. The device is almost like training wheels for resiliency that over time it helps us get better and better and stronger as we use it.

About Dr. Dave Rabin and Apollo Neuro

Heather Sandison, ND: That's fantastic. If somebody wants to purchase Apollo or learn more about it, what's the website.

Dave Rabin, MD, PhD: The website is apolloneuro.com. It's A-P-O-L-L-O N-E-U-R-O dot come, and you can also go to apolloneuroscience.com, and you will find us. We have awesome articles about the technology, our studies that are ongoing and upcoming, and lots of information about not just the technology but also understand how to improve your resilience for free with sleep techniques and breathing techniques as well, which I think are so, so important and really the foundation of all of this work.

If you also want to reach out to me, you can check me out at Dave Rabin on Twitter or @DrDavidRabin on Instagram. Apollo is on there too. I'm happy to stay in contact to answer any questions that you have. My website for my clinical practice is Drdave.io.

Heather Sandison, ND: Great. And are you still taking clients?

Dave Rabin, MD, PhD: I am.

Heather Sandison, ND: Oh, fantastic.

Dave Rabin, MD, PhD: Yeah.

Heather Sandison, ND: Where are you located?

Dave Rabin, MD, PhD: I'm located in California. I practice in Pennsylvania and California, but at this point I believe given the COVID situation that a lot of restrictions are being lifted by states that allow doctors to provide care outside of their state of current licensure, so that will be evaluated over time. But at this point it looks like we're going to be able to provide care to not just people in California or in Pennsylvania. Hopefully, the access to this kind of care will get better and better. We have a lot of colleagues around the country who are working with us to help improve that as well.

Heather Sandison, ND: Great. So there's some gifts coming out of this crazy crisis situation. Dave, thank you so much for your time today and for sharing these insights with us. It's been a real pleasure having you today and such valuable information especially considering the current crisis we are all facing as a planet, everyone in the world. No one is escaping being touched by this at some level. Thank you for sharing these very hopeful nuggets about how we can really benefit from these tools that we have at our disposal.

Thank you, thank you. It's been an absolute pleasure.

Dave Rabin, MD, PhD: It's my pleasure. Thank you so much, Heather. I really appreciate it.



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