[JOE SANOK] This is the Practice of the Practice Podcast with Joe Sanok, session number 796. I’m Joe Sanok, your host, and welcome to the Practice of the Practice Podcast. I am so excited that you’re here with us today where we are talking about starting, growing, scaling, and maybe exiting your private practice, everything private practice around marketing, clinical just the behind the scenes as well as the forward facing things. I just love being able to dive in with experts in their field around just different topics and to be able to just dig in in a little bit longer episode, which is why I’m really excited to have Dr. Justin Bethany with us today. In practicing psychiatry for the past 10 years, Justin’s gained a greater understanding of the connection between the mind and body. After spending the better part of his career incorporating functional and integrative approaches to mental health treatment, Justin gathered all of that knowledge and compiled it in an easy to digest book entitled The Mental Wellness Diet: Ancient Wisdom, Evolving Science, Modern Day Options. Justin, welcome to the Practice of the Practice Podcast. Really glad you’re here today. [DR. JUSTIN BETHONEY] Yes, thanks for having me. I’m excited to be here. [JOE] Yes, yes. Well, we overcame some tech problems, so already I feel like we did a team building activity, so that’s great. Well I want to start with, instead of starting with the psychiatric or your book or things like that we were just chatting about how when you were starting your practice there were some issues behind it. Would love to hear that story of courage and just starting your practice. [JUSTIN] Yes, thanks for that. I’ve been practicing a little over 10 years, and I’m a nurse practitioner with a specialty in psychiatry. I started working for clinics and private practice psychiatrist-owned practices. Then throughout school and throughout my first couple years working, I was interested in integrative medicine and spending more time with patients and just providing better care, working around the edges and just doing more for people. Unfortunately, with the healthcare system time is tight and time is money. So when I was working for other people, it was really limited, so I wanted to branch out on my own. Around 2015, I had moved to California. California’s a great state but not very open to nurse practitioners and independent practice. Many states across the country are now allowing nurse practitioners to practice “independently.” What that means is they can practice without a physician oversight, and that’s wonderful. I mean, then a nurse practitioner and psychiatry, or possibly other specialties can hang their own shingle and open their own practice. But in 2017, when I started my own private practice in California, there was still this rule where I needed to have a physician “collaborative physician,” and we needed to have standardized procedures and signature page. So the physician, and many physicians do this, psychiatrists or other physicians will sign this document for nurse practitioners allowing them to start their own private practice. However, in doing that, a psychiatrist would take on a lot of risk. They can be named in a lawsuit, but they wouldn’t necessarily be found guilty or whatever if they didn’t consult on the particular case that there was problems with. So that shied a lot of psychiatrists away so in 2017 when I had all this enthusiasm and motivation and really wanted to start my own thing, it turned out I got a lot of doors closed on me. Many of my psychiatrists friends that I’d asked other physicians, everybody said, I really wish you the best of luck, but I’m sorry, I just can’t. I understood it would be a, it’s a really big ask. Luckily, I eventually found a doctor who was just one of the nicest guys I’ve ever met, and felt there was good karma in it. He said something along the lines of, well, this is going to help you help more people, so me helping you helps out as many maximum peoples as I possibly can. So that was a turning point for me. It was nerve wracking. It was scary. There was a lot of pessimism. Then it finally broke and it finally came through, and I finally got all my signature pages signed, and then the hard work began of actually starting the private practice. [JOE] So when you were first getting your nurse practitioner practice going how did you get people to find out what you were doing? How’d you figure out your specialty, your angle, I mean, those are all things that our listeners deal with when they’re starting a practice too? [JUSTIN] I entered a saturated market. I was in the South Bay, which is the beach cities in Los Angeles, and there probably could have been more psychiatrists, but there was already some really well established names. I decided not to take insurance because I was going to spend extra time with patients. I did a lot of work on Instagram. I put together a lot of educational videos. I did other forms of advertising, but the thing that actually helped me the most was this meetup group that I started. The best thing I ever did to get the practice going was networking. So I would meet with therapists, and that was a real advantage for me because I guess it’s a stereotype, but the typical psychiatrist doesn’t really have the time to call back or meet with or get to know therapists. I’m pretty sure many people in your audience would understand that that’s, they’ve had experiences similar to that. I mean, there’s plenty of exceptions, and there’s really great psychiatrists out there, but I felt that that was a competitive advantage for me, so I went on a ton of coffee dates and met up with people all over town and became friends with them. Then I got this really good idea, which really worked out well for me. Across the street from my office was this big huge coffee shop, and it had a back room. So I created this meetup group, and it was all therapists who were invited. Then I would have one of the therapists, because every therapist is interested in their own little niche, so there was an art therapist that did a presentation, the acupuncturist from my office, she did a presentation. The chiropractor from the office that I rented, she did a presentation on posture, which is so important for us, therapists sitting in chairs all day. Then each of the therapists went, and then some of my other psychiatrists friend came. It was great. It was social, which is really important for a career that can be really lonely. It was social it kept me top of mind because I was hosting and people were constantly getting an email from me every month inviting them to come do something fun and I would moderate and host. So my voice was present and that helped, that definitely helped. Not every patient that was referred to me from the therapist worked out because it didn’t take insurance and it was cash pay but it was a lot of goodwill that helped pay off and helped build the practice in the early days. [JOE] Tell me a little bit about some of the concepts that led up to the book, so how were you learning, growing, integrating all of that into your practice before you wrote the book? [JUSTIN] Yes, the book is a real culmination of all the things that I’ve learned and studied and talk about with patients. Actually, the book was a lot easier to write than I thought, and it was a lot harder to edit than I thought. I edited it myself several times over. If you’re just pumping out and typing away and you write things, you don’t really realize how many typos are in there. So I had to clean it up several times. But writing it was really easy because it was a conversion from the way I would speak and explain and provide psychoeducation to my patients, the analogies that I always use, the concept that I talked about, guesses on what was going on with, with people’s symptoms or medication reactions and then the connections between the body with inflammation and gut health and various neurotransmitters in the brain. So it all flowed from my brain onto my laptop, and it was pretty easy. We can we can get more into some of the topics of the book, if you’d like. [JOE] Well, why don’t we dive right in? Give us a big picture overview of the book, and then maybe we can dig into some of the of more nuanced parts of it. [JUSTIN] Great. So the book is two parts, maybe. The first part is a description of the mismatch for us as human beings in modern day life and the diet, so to speak, which it isn’t really necessarily a very prescriptive or a diet instruction heavy book. It’s more about, here eat these foods because of this concept called nutrient density. Nutrient density is for every bite of food you take in how many vitamins, minerals, proteins all the essential nutrients are jam-packed in that bite of food. You want to try to go for the foods that provide the most amount of nutrient density. So that’s the basic concept. Then the diet, the foods recommended flow from that concept of nutrient density. Anyways, the first half of the book is about, or the mismatch we experience now in modern day life, modern day life is amazing, and there’s so many options, and there’s so much ease and comfort and guarantee so it definitely beats out feast and famine and cold winters and tigers from ancient times. But things are much more complicated. Things are much more heavy, and there’s a lot more insidious subtle pressures in our society that are really destructive. These are things that I even see day-to-day in my office, things like shame and guilt, some of these abstract things, abstract pressures that really weigh us down. So the first half of the book calls that out. Then the second half of the book gets a bit sciencey. It talks about the five, I created five functions of the brain and body and what needs to happen and when it happens correctly, we’re good and when things go awry, we can experience the outcome of mental illness symptoms. So those five science parts are functions of the brain and body are fuel. You need fuel for your brain, and that relates to mitochondria. You need to be able to respond through neurotransmitters. Neurotransmitters need to be there. They need to be used, they need to interact with receptors and then they also need to be metabolized, broken down, and eliminated. Build is the next one where neurons are very delicate structures, and they need the right fats, and they need to be flexible and fluid. If you have all those components, you’ll have great communication in and across the brain. If you don’t, there can be problems and mental illness symptoms can result. The final two is balance and protect. Those two relate and this is this concept of how inflammation can cause depression. What’s underneath that is there’s a lot of evidence pointing to low-grade, chronic systemic inflammation getting into the brain, irritating excitatory receptors, causing over excitation, and that over excitation leading to various symptoms, anxiety, dark stormy, depression, even psychosis and other serious mental illness symptoms. So that’s the book. [JOE] Wow. So before we dig into a little bit more of the book why do you think it’s important for therapists, counselors, psychologists, social workers, MFTs to have at least a working understanding of these concepts? [JUSTIN] Well, I actually did this presentation in one of my the first meetup group. I was the first presenter for my first meetup group and actually looked into, in southern California, there’s a lot of LMFTs. So I researched the scope of practice, which has a clause in there about helping people’s overall health and helping people in the direction they want to go in reaching their goals. There’s nothing illegal about psychoeducation. Obviously, you want the psychoeducation to be accurate but people live a whole life. In healthcare, there’s a pressure to dial down in a PHQ-9 or a GAD-7, and then if you don’t, somebody could have a low PHQ or GAD-7, but still be, I guess, unhappy or unfulfilled or unsatisfied. So a therapist, that’s our domain too. You don’t necessarily need a mental illness full on meeting criteria disorder to gain benefit from meeting with your therapist. That relationship has so many benefits in healthcare and checking the boxes and dotting the i’s and crossing the t’s, I think that gets lost because there’s so much pressure for us to be robotic [JOE] I think also just scope of practice, the average therapist maybe isn’t taking the time to really learn about the nutritional side of mental health. So not wanting to step too far outside of where our own expertise or comfort level is, I think a lot of people just don’t really address it. They might say what you’re eating like in the intake, but it isn’t maybe a whole part of how they think about their clients and that work. Now, when you think about what you would hope for therapists to start to integrate into their practice, what do you hope from your book or from even your own practice? Would you hope the average person that’s not going to spend time getting certified in nutrition, they’re not going to do terribly deep dives, but some of the basic stuff that you would hope that they would start to integrate into their practice? [JUSTIN] Helping people move in the direction they want, which is part of that scope, more, it just needs to be more that there’s in our modern day life. The way it works in human nature is there tends to be gravitational pull downward. That’s something that we all need to resist every day. So from one patient to the next, you can be agnostic. I know I am, some people where I live in Bend, Oregon their only form exercise is rock climbing, which is amazing that. But they don’t need to do the 45 minute cardio to get the BDNF boost and the serotonin surge and the endorphins gone. As long as you’re doing more for yourself. That invitation, I think is, I guess maybe hard to explain, but I think most therapists, all therapists in your audience would understand what I’m talking about, the invitation to do more for yourself. It’s one of the key aspects of treatment I feel. [JOE SANOK] When I had my group practice, I was so sick of running to the lobby to see if my next appointment had arrived, or even more awkwardly to have a bunch of therapists run to the lobby when we heard the door open. Maybe you want a more discreet, stress-free way for your clients to check in. Take a deep breath. The Receptionist for iPad empowers your practice to create a zen-like check-in experience. This episode is sponsored by the Receptionist for iPad. It’s the highest rated digital check-in software for therapy offices and behavioral health clinics used by thousands of practitioners across the country, including many who are just getting started. The Receptionist for iPad is super simple. It’s an inexpensive way to allow your clients to discreetly check in, to notify providers of a patient’s arrival and to ensure your front lobby is stressed free. The software sends an immediate notification to the therapist when a client checks in and can even ask if a patient information has changed since their last visit. Start a 14-day free trial of the receptionist for iPad by going to the receptionist.com/practice. Again, that’s the receptionist.com/practice, and when you do, you’ll also get your first month free when you sign up, [JOE] I want to dig into those five functions of the brain and body, so you had fuel, respond, build, balance, and protect. Maybe give us a quick synopsis of each of those. [JUSTIN] Sure. respond, respond is really, that’s probably the one that’s been the most publicized or well known. I know there was that just study that came out citing that the amount of serotonin in the brain doesn’t matter and the serotonin hypothesis doesn’t is a myth. But then antidepressants still work. So that new story moved the ball forward a little bit, but not too much. Neurotransmitters are central and neurotransmitters are our key players. I think the problem with that, the chemical and balance theory or the serotonin hypothesis where okay, you’re depressed, you need to take Prozac because you don’t have enough amounts of serotonin, that’s obviously was an oversimplification. Then the new research coming out shows that it’s not that serotonin doesn’t matter, but it’s just that that was an oversimplified understanding of the situation. So there’s birth and death with neurotransmitters and they do different things. You need to have the raw materials, which is where nutrition comes in to create them. You need to have them be in the vesicles at the end of neurons ready to be released, you need to have stimulation, environmental stimulation, activity behaviors, interactions with others, watching sunsets, eating your favorite food. That stimulates, causes the release of things like serotonin and dopamine so you have the release, and then they have to interact with receptors. Then once they interact with receptors, they have to be eliminated, degraded, and removed because it’s goldilocks, you want enough, but you don’t want too much when it comes to neurotransmitters. So how the book comes in handy is in the back of the response chapter on neurotransmitters. It shows a table, it shows all the vitamins and minerals and protein factors and all the essential nutrients that participate in each one of these birth and death steps of neurotransmitters. B vitamins are really critical. Iron, so many people are either iron deficient or so iron deficient that they’re then anemic, and that is a major cause of their fatigue, low energy, malaise, and Prozac won’t help raise their iron levels. So some of these connections are really basic and really important. Anyways, that’s the neurotransmitter response chapter. Then there’s four more if you want me to keep going. [JOE] Yes, keep going. [JUSTIN] Sure. Build, build is the next one. Build is about that fatty outside covering of those neurotransmitters. The neurotransmitter neurons themselves, there’s a saying in neurology that things that fire together wire together. So think of a well-worn path in the woods. If you grew up around the woods imagine tromping through the forest with no path, it would take you forever but then imagine crossing that same forest down a well-worn path. It’s a fraction of the time. So in the brain connections from one neuron to the next, to the next is a pathway. Those pathways or circuits become well worn. This is like riding a bike. When you’re first riding a bike, it’s awkward, it’s scary. You just can’t feel the bike underneath you but sooner or later, it’s, you’re riding the bike and talking on the phone and talking to your friend and waving to your neighbor. It’s so automatic and that automaticity is because of those well-worn pathways. So to have well-worn pathways, you need to have fluidity, flexibility and you need to have healthy fats in your outer surface, your outer membranes of those neurons for them to function well. So those, there’s a list of nutrients, mostly Omega-3s and some other nutrients that are really essential for creating those healthy, building those healthy structures. The next chapter is fuel, and that’s all about mitochondria. Your brain needs energy, especially a very critical part of your brain, the frontal cortex. The frontal cortex is our adulting center of our brain. It helps us think and plan and remember, and remember working memory. So where we remember, we hold something to the side of our brain when we’re working on something else. This is, so if you have good working memory, you don’t burn your toast when you put it in the toaster because you remember to go back and get it. So these are really helpful skills to have, especially in modern day life and to be able to have the frontal cortex do its thing, you need energy. That energy comes from the form of mitochondria. So again the back of that chapter, you’ll see a big table with all the nutrients that are essential for mitochondrial function and health. Then the last two are related. Protect is about that, there is an immune system interlaced, interwoven all throughout the brain, and that’s essential because we really need a very clean, pristine disease-free, foreign, substance-free brain for our brain to function. That’s why there’s so much, so many glial cells. Glial cells are immune cells, and they’re also the mortar in between the bricks in the brain. So they’re essential. But again, that goldilock principle, you need some inflammation to clean up dead cells, foreign substances, any sort of infection that might reach the brain. You definitely need those sentinels active and ready. But in modern day life with all of our toxicity and pollutants, dirty water, dirty air, junk food, stress itself is inflammatory. All those factors in modern day life overwork the system. They definitely irritate the brain, trigger more than is necessary immune response. When that happens, some of those excitatory receptors in the brain can get overactive, and then thus produce some mental illness symptoms. That relates to the last one, which is balance. So imagine serotonin and dopamine, these very important neurotransmitters. These are like, imagine a city, these are like the stoplights dotted along different parts of the city, but all the cars have a gas and a brake. In the brain we have excitatory neurotransmitters and excitatory receptors. So those glutamate is a major excitatory neurotransmitter and NMDA and AMPK. Those are the, they receive those excitatory signals. Those would be the gas. Then gamma aminobutyric acid, or GABA would be the main, and there’s GABA neurotransmitters, and then there’s GABA receptors. These ones are the main break. If you’re driving down the road 40 miles per hour, and then your turn’s coming up, you wouldn’t just hit the gas and jerk the wheel. You’d crash. So to have this ability to control yourself and control your emotions and control your thoughts and feelings, you need to be able to tap on that break and that would be the GABA. There’s a host of nutrients for that as well that support the creation and utilization of GABA. Then there’ — [JOE] Now when you think about, oh, sorry, go ahead. [JUSTIN] Oh, and then there’s obviously another table of nutrients for the protect chapter, which is a counterbalance against our chronic inflammation that we experience. So those would be the Omega-3s, vitamin A, vitamin D, vitamin E, and a couple others. At the back of that chapter, there’s tables for all of it. [JOE] Gotcha. I’m sure that it’s tough to oversimplify this and to say, here’s like the five foods that you should eat, but for you personally and for the people you work with, are there foods that are go-to foods for you that you want to make sure in your diet every week or that you’re throwing into green smoothies or things like that? [JUSTIN] Yes, probably more. I probably take the other angle. I put change in people’s diets underneath religion and politics. It’s hard, and that’s probably ironic coming from a guy who wrote a book about mental wellness and nutrition, but it’s probably more about what you remove than about what you add, yes basic multivitamin and some extra vitamin D, definitely some extra magnesium. These are things that are good covering your bases, Omega-3s. Those can be in the form of supplements. Then in those, in the back of the chapter, the columns for the table for the nutrients that affect each chapter is the name of the vitamin or mineral, and then the food sources. That’s the reason why I created those tables, was to help it be individualized. If someone read the protect chapter, if someone read the balance chapter and said these symptoms here, and this, these analogies, this makes sense to me, this is what I need, well, then that person should go to the back of that chapter and focus on the foods that have B6 and toring and glycine. So I think that’s how I’d answer the question. But overall, I think it’s more about getting rid of the sugar and the trans fats and the fried food and excessive carbohydrates. Those would be the top things to focus on. [JOE] Yes, it’s interesting. My daughters, one thing that I do with them is we try to talk about how’s the food make you feel and things like that. Just yesterday my daughter was going to have some goldfish and she said, I’m not going to eat anymore goldfish. I’ve had enough carbs today. It’s like, okay, she’s noticing how our body feels. It’s interesting those little things, like even just putting something healthy like some shelled pistachios in front of the little bit of junk food that I allow in the house to say, let’s make good choices if we want something salty but to also allow a little bit of that stuff in our life. The last question that I ask everyone is, if every private practitioner in the world were listening right now, what would you want them to know? [JUSTIN] Well, a big part of my book is about exceptionalism. I don’t think I coined that term, but I used it a lot in my book. Exceptionalism is my description of our modern day life and how there’s this pressure to be exceptional or perhaps even perfect or flawless or not making mistakes, all these things. But I think that definitely dilutes our own unique flavors and personalities. The patients that would come back to me when I was, had my cash pay private practice were the ones that liked me. They liked the way I talked, they liked my jokes, they liked the information. in my office, I have a big whiteboard, and so many of these concepts I was telling you about today I would map it out on my whiteboard in the office. Some patients didn’t like that. Some patients didn’t like, like my jokes. Some patients didn’t really want to hear psychoeducation. They just were at a point where they just really needed me to fix it. So I learned after a few years of the private practice that it’s all right, you’ll make enough money, things will work out, you’ll get your reputation. They’ll be mostly good, some bad and that’s all really good because being yourself allows you to enjoy your job and in many different ways, it will help the right people find you. So be yourself when you’re networking, when you’re with patients, when you’re case conceptualizing and providing education. Yes, just try to focus on your actual authentic self and trust that it will work out. [JOE] That’s so awesome. Well, Justin, if people want to connect with you, they want to follow your work what’s the best place for them to connect with you, your work and your book? [JUSTIN] Thanks for that. The website is a great place www.thementalwellnessdiet.com, thementalwellnessdiet.com, and that has a lot of information and some embedded blogs and Instagram posts. Then it’s got a link for the book. Recently, I paid for a service to create an audio book. So it was read by a computer, but sounds really great. That’s an interesting thing. Then you can purchase that on the website, and then there’s links to Amazon if you wanted to purchase the paperback. Then there’s [email protected] com. That would be my email for anybody in the audience who had any questions or wanted to reach out or any comments or anything. Yes definitely an open book. [JOE] That’s awesome. Well, Justin, thank you so much for being on the Practice of the Practice Podcast. [JUSTIN] Yes, thanks for having me. [JOE] The great thing about having a podcast is that you can have these deep dives that you can really dig in with people. If you haven’t checked out podcastlaunchschool.com, we have a whole tutorial totally free for you to get started in podcasting. That’s something I haven’t mentioned in a long time, but we put that whole course together. I’ve got some discounts over there on that as well if you want to buy the course or if you want to get the free email series that goes along with it. We couldn’t do this show without our amazing sponsors. I remember when I had my private practice before I sold it in 2019 we had a four office suite, had a view of the water this great place, and if the other therapists and I were waiting for someone, say it’s three o’clock, and the door opens, we’d all come poke our heads out like we were ostriches or something and oh, that wasn’t my person. Oh, that wasn’t my person. I wished that I had something as simple as the Receptionist for iPad. It’s an inexpensive way to allow your clients to discreetly check in, notify the providers of their arrival, and make sure that your front lobby is stress free. Man, can I read this today? What the heck? You can sign up for a 14-day free trial of the Receptionist for iPad by going to the receptionist.com/practice. When you do, you’ll also receive a free $25 Amazon gift card. I’ve got to know the folks that made the Receptionist, and it is honestly the tool that I wish I had when I had my practice. Again, that’s receptionist.com/practice and would love for you to start using this on your iPad for people checking in. Thank you so much for letting me into your ears and into your brain. Have a great day. I’ll talk to you soon. Special thanks to the band Silence is Sexy for your intro music. This podcast is designed to provide accurate and authoritative information in regard to the subject matter covered. This is given with the understanding that neither the host, the producers, the publishers, or the guests are rendering legal, accounting, clinical, or other professional information. If you want a professional, you should find one.