Dr. Jasmine B. MacDonald (00:08):
Hi there and welcome to this episode of Psych Attack. I'm Dr. Jasmine B MacDonald. And today I'm catching up with Ryan McGrath to explore the intersection between physiotherapy and psychology. I hope you're going well and have that cup tea ready to go.

Dr. Jasmine B. MacDonald (00:30):
Hey there, Ryan. Welcome. It's so good to have you here today.

Ryan McGrath (00:33):
It's nice to be here.

Dr. Jasmine B. MacDonald (00:34):
Your work I think is particularly fascinating because you draw these two disciplines together, physiotherapy and, and psychology. But before we kind of jump into that, a nice place to start might be for you to introduce yourself and the training that you've done.

Ryan McGrath (00:49):
So I'm currently doing a Ph.D. at Charles Sturt University. I'm also a registered physiotherapist working one day a week at a refugee health clinic in Victoria. My training has predominantly been in physiotherapy, but I pretty much started, I started physiotherapy in 2016 and I had always had an interest in psychology. I was tossing up between physiotherapy and psychology and after doing my first psychology subject as a part of physiotherapy. And that's the only one you really do in, in, in the course that I did at Charles Sturt University, I then, you know, went to apply for concurrent studies is in psychology and physiotherapy. And they were "like, no, you can't do that". And I'm going, "oh, but there are ways you can do it over summer. I can make it happen". And they said, "no, we're not allowing that". So I went and did single subject study for my first two psychology subjects. And they were pretty much a repeat of what I did in physiotherapy, but they were, you know, APAC [Australian Psychology Accreditation Council] you know, psychology, accredited subjects. And then I went back and said, "look, I've already started here are my grades, let me in". And they finally did let me in. And then since then I've um, completed nine psychology subjects. I was planning to, I'm like almost finished an equivalent of a grad dip [graduate diploma]. And I'm hoping to do that in the next couple years, but at the moment, my passion's in research and practice and psychology's slowly coming along the way.

Dr. Jasmine B. MacDonald (02:08):
Yeah. Okay, nice. I really like that. You just essentially didn't take no for an answer.

Ryan McGrath (02:12):
No.

Dr. Jasmine B. MacDonald (02:12):
It's like, yes, this can work and they are complimentary. I, I shall do this

Ryan McGrath (02:18):
It was worse in my first semester uni I sent actually the first email going, is this possible? And now looking back, I'm going, I hadn't even finished my first semester of physio and I'm going here and saying, let me do this thing. I've worked it out and all that type of thing. And they still went, "no". And then I went an email back again and again, and I just really probably annoyed them to the point they let me in and all the way through at the start, and I find this really funny now that I was asked, "why would you want to do physiotherapy and psychology together?" Like, "what's the relevance and why is that important?" And at that stage in my physiotherapy journey, I had a simple answer and that was, people are complex, there's mental health and physi, physical health together. But now since doing more research learning a bit more about, you know, being a physio, learning more about psychology and learning more about the intersection between the physi, physical health and, uh, mental health, which really we just think about as health and wellbeing, it's really much easier to justify, complicated answers, but easier to justify.

Dr. Jasmine B. MacDonald (03:13):
Yeah. So I, I think that kind of evolution in your thinking and motivation is really interesting. Could we maybe talk about physiotherapy for a second if we assume like the listener or assume I don't know what a physiotherapist does, could you tell me about that and then, and kind of add how psychology assists with what a physio might do.

Ryan McGrath (03:34):
That is a very, very, very difficult question and a question that I have to contend with...

Dr. Jasmine B. MacDonald (03:39):
You're welcome.

Ryan McGrath (03:40):
No, it's, it's really fascinating. Um, when I, cuz at the clinic that I'm currently working at, I'm working at a refugee health clinic and I'm employed working as a role as a physio, but what is a role as a physio in this health clinic? It's probably easy to describe what I do and see how that, you know, people have their own preconceptions of what physiotherapy is and I'll explain what my practice looks like. So...

Dr. Jasmine B. MacDonald (04:00):
Cool.

Ryan McGrath (04:00):
I started at the refugee health clinic in November last year and that was all during COVID. So it was lockdowns mostly on telehealth. So I, when I got the job, I, there was a physiotherapist already working there for most of the lockdown period and I, and they said, "yeah, it'll be telehealth" and I'm going, "okay, that makes sense. It'll be video, I'll sit down in front of a screen and I'll talk to these people and we'll go from there". And that's the way I can watch people move, do gait analysis, still talk them through their story and explore all that. But I, I would have that visual information. I get there and no, the clients that we are working with, it wouldn't be accessible to be able to be able to do that traditional telehealth, it's most, we, I actually never use is video in my role. It's only over the phone because that's, what's works with, with the clients that I'm working with. And mostly they present with referrals from their GP for persistent pain. So pain that's been lasting sometimes short term. Sometimes it's new. It's only been around for a couple months and generally it's a couple months by the time that I get to see them. And they've had a, um, they've tried medication and those type of things. But mostly I, I see a lot of clients that have had, you know, persistent pain, five, 10, sometimes even 20 years. So...

Dr. Jasmine B. MacDonald (05:07):
Mm.

Ryan McGrath (05:09):
But already I found it very different, you know, I was only working on over the phone, so I didn't have those typical tools that you'd think, you know, even that I've learned, I couldn't do, um, gait analysis. I couldn't watch people move. I definitely couldn't touch them anyway and do all my assessments that way. And I couldn't read any body language back and developing rapport was different, but I've found it very, very freeing and very interesting. And it's really challenged what my idea is of physio and how that relates back to your main question is what is physiotherapy and how, what does physiotherapists do? There are over 20 areas of physiotherapy practice that people kind of work in. That's what they've argued that an undergraduate physiotherapists has to be competent in, in reality, that can really be boiled down to three cardio, respiratory practice, musculoskeletal practice and neurological practice. They're the main three that most physios work in. And most of 'em work in musculoskeletal. So that's the traditional people think about you go there, you get a sore knee, you get a sore shoulder, you go and see physio either directly, or you go through a GP or something like that. Neurophysio is, are the ones that people think about when somebody suffered a stroke or had some sort of neurological condition and people think of about them more working in hospitals. That's why it's not as accessible to the public. It's something, you know, you have an injury, you have a stroke you're sent to the hospital and then you'll see a physio for the next, you know, for, for the rest of your life generally. But you'll see them quite intense for the month afterwards. And in cardio resp nobody really understands the role of physio from the general public and that one, unless you're living with a condition like, um, COPD, which is construc, um, chronic obstructive pulmonary disease and those type, or cystic fibrosis. And that's where physio's all about lungs and breathing, but there's quite a large diversity in practice. And what physios do varies greatly depending on their working and what they've learned and how they develop their own practice in it.

Dr. Jasmine B. MacDonald (06:56):
Yeah, absolutely. I mean, and when you say there's 20 areas of like practice focus, I think in psychology, we have what, seven or eight or something for, um, endorsement. And that seems massive. So , it's quite a diverse field.

Ryan McGrath (07:10):
Our skills overlap generally in those areas, common thread sort it's, again, back to the tradition of physiotherapy practices. It's very, you know, it's it, the Americans call it physical therapy. It's the idea that it's a physical body that we work with. So really physiotherapy is filled every single void where you probably need somebody who has considerable knowledge of biomechanics, biology and is, is probably a little like is more trained than a nurse in that role. We've specialized. We've got that more of autonomous practice. Of course there are nurses that go out there and become things like diabetes educators or nurse practitioners, but physios, we're trained to be autonomous practitioners and we fill every role that we kind of get sent into. So that's why, you know, you need a physi, you need somebody to help people, um, with COPD. So we train physios up cause they know a bit about lungs and breathing and then that's a natural progression same thing with disability or gerontology. So working with older adults, you know, that's restrictions on movement. So really anything that movement to do with, but there's a lot of things that can affect movement. And I think that's probably where this conversation will go.

Dr. Jasmine B. MacDonald (08:12):
Um, really keen to talk to you about your research, which has worked to unpack kind of encounters between physiotherapists and clients they work with that might have suicidal thoughts and behaviors. So maybe you could just provide a bit of an overview about that and, and like, what's interesting about this topic, what drew you to it?

Ryan McGrath (08:31):
What I'm interested about. And I'm interested in really all those areas of practice because it's so diverse physiotherapy practice, but the ones that I know most about, and there's been more discussions about is private practice, physiotherapy, that's where the majority of physios work. And it's also in many areas it's quite isolated physios, generally, you know, um, collate or group together in large physio practices or even by themselves, it's often not very common to see multidisciplinary physiotherapy practices. And when you do see them, they bring on things like exercise physiologists or occupational therapists. And they're kind of similar as well in terms of...

Dr. Jasmine B. MacDonald (09:04):
Okay, so they herd in nature.

Ryan McGrath (09:05):
Exactly. There's and they get bigger and bigger. And then, and they develop kind of echo chambers amongst them, which is really cool. Cause you have lots of different, you know, each physio generally practices slightly differently, but we all kind of drawn the same evidence, the same research base and the same way of thinking. So how that relates to the, my work with clients with suicidal thoughts and behaviors and physio experiences with them is that I was interested because we work when you are working in musculoskeletal private practice, you are dealing with people with persistent pain and associated with often persistent pain or any type of pain is disability and independence and function. And that by itself is quite a stressful situation, particularly when, you know, some of these injuries and some of these, um, issues that people can have can be really, really, really stressful and have some long term detrimental impacts or they can be perceived as having quite a long term detrimental impact. So for example, you know, lower back, pain's one of the highest, um, conditions in terms of disability and burden in the health system. So we talk to these people and because we're isolated and practice and we're first contact practitioners, people come in and tell you their story. And physios are meant to, particularly when they're working in pain and all areas of practice, but particularly in pain to complete a biopsychosocial assessment, which in other words means we look at biological factors, we look at psychological factors and we look at social factors yet our training generally is skewed to knowing the biological biomechanical factors in that equation. Yet we, we are encouraged to do all of it. And there's a couple other approaches too, that are really encouraging, you know, physios to ask more open questions, like, tell me your story. You know, how did you get here? How's this affecting your life? Does this get you down? So when we're exploring these type of questions, we're opening up dialogue in terms of psychology and mental health. And my question was, you know, when we're having these conversations, where does it go and suicidal thoughts and behaviors was I very small area of research. Like it's great. It's quite easy to operationalize and talk to physios about, distress is of much larger concept. So I was asking about, you know, how, what happens when you're having these conversations and somebody expresses something like extreme hopelessness or helplessness, or they feel like they are a burden, those type of things. How, how do you cope with that? And do you ask about suicide? And then what happens when somebody discloses overt suicidal thoughts to you? How do you handle that situation and how do you feel about it?

Dr. Jasmine B. MacDonald (11:27):
Mm-hmm so who did, who, you know, roughly, did you talk to, and how did you try to answer this question?

Ryan McGrath (11:33):
The way that I wanted to go about it is of course it would be really interesting to ask clients about their perspective, but that's a, that's a very interesting group and there's not a simple way to get access to people with suicidal thoughts who have gone and seen physios. It's not something that they particularly in these type of encounters, there's not necessarily a big frequency of this event necessarily happening. Um, a literature review that I was writing estimates, probably two to five clients had, you know, per week on a lower end of an estimate would have suicidal thoughts, um, that a physiotherapist is seeing. But there's probably, it's probably more than that, but also those two to five clients might not disclose that information to a physio or that, or a physio might not detect that type of information. So, so for me, I was really interested in what's a physiotherapists perspective and how do they cope with it? So in that way, it led it towards doing indepth int..., You know, one on one interviews and focus groups, both ways are quite interesting. Um, focus groups allow, essentially participants to go and talk about their experiences, challenge each other and explore. And I can essentially, as a researcher sit back and just watch the dialogue and the conversations happen. And I find that really interesting. Whereas when you do interviews, it's a lot more intimate. You can go into greater depth, but you're a much larger part of the research process. So that's how I answer those research questions by literally getting groups of physios together in one focus group, and then the one getting, um, a series of four or five interviews with other physios and talking about, you know, what do they do? How does it feel? And just, and starting from there.

Dr. Jasmine B. MacDonald (13:02):
I think that's really, um, fascinating because that method of including focus groups seems to reflect what you're saying about practice. If, if physios tend to practice in, you know, not an in individual person in private practice, but actually a group of physios working together, then likely the, um, kind of practice conversations that they're having, or, you know, um, kind of consulting with each other about a client, then collecting data in that way makes a lot of sense. Maybe even more ecologically valid than potentially for other professional groups.

Ryan McGrath (13:34):
What I found very, very interesting about doing focus groups and this wasn't the intention to do this. It just was, happened together when you're doing convenience, you're trying to get people who are willing to talk to me. I'm like, "I'll talk to any physio with this experience. So come and find me and then I'll, I'll essentially talk to you whenever you want to talk to me. And in a situation that's comfortable for you". So we ended up have being a situation where five physios from a single practice, all had experiences and all were willing to participate. And in that way it made it a lot of sense and they were happy that like, this is what they wanted to do. They said, "we'll stay late after work one day and we'll get all our physios together". Like, the five that were interested, they got more physios that didn't have experiences or weren't able participate for other reasons. But the five that were interested in, they were like, "let's do a focus...". You know, essentially I was a willing to a focus group. And so we got them all together. And so what, what you are getting at Jasmine is that this was from one practice. These people worked together side by side, and one of the physios was talking about how they encountered a client with suicidal thoughts and behaviors. And it was quite intense feelings of suicidal ideation. The person came in reportedly on some pain medication. They weren't, were pretty much in a crisis where reportedly in and out of consciousness during the consult. And that physiotherapist called up another physio from their own practice, cuz this was one practice, but multi regional or multi-centered and the other physio was there. So we had both physios, the one who was actually with the client and the one who actually reached out to. So I found, you know, that type of, as you're saying, it was really, really interesting having a group that works together and then actually being able to, and really let them talk with between each other. So they talked about how it all felt to them and said, "yeah, they called me and this is how I talked them through. And then they went back" and it was much more interesting than you would've got from an indepth interview or you wouldn't have got the same type of information from an indepth interview when you've only got the one physio there and they said, "I called somebody else". And then, you know, I got both sides of the story.

Dr. Jasmine B. MacDonald (15:30):
Yeah. How cool have that, you know, triangulation of data and be able to bring it together. That's awesome. So, um, you have these in depth interviews, you have these focus groups, uh, what kind of things were the physios telling you about their work with clients they thought might have suicidal thoughts and behaviors?

Ryan McGrath (15:47):
What's interesting is that while the discussion was about suicidal thoughts and behaviors, it drew on much more of how physiotherapists approach, just every single patient, because physios, aren't going out there and saying, oh, "I've got a client, who's got mental health concerns. I'm gonna focus on that". Or because that's not, that's not their, particularly in private practice. That's not the reason the, the, the client's presenting to you. They're presenting to you generally as a referral or of know, um, self referred for, you know, knee pain should pain. As I was saying before back pain. And it just happens during a consult that these things emerge. So physios were talking about how with every single patient, they want to build trust because this is a relationship they wanna have with a, with a, um, with a client over a period of time. Musculoskeletal conditions aren't things that you a cure. My, um, partner studies podiatry. And she talks about how, when they do in, in grown to surgery, it's just a quick fix. She loves it because they come in with pain, they do the surgery and then they're out. And they, they no longer experience their pain because they've had the surgery and they've had the solution. Whereas musculoskeletal physiotherapy is not like that. It takes time and tissues take time to heal, confidence takes time to, you know, build up. Um, strengths takes time to, you know, again, similarly build. So these physios want to build a trusting relationship over a period of time. And to do that, they use two types of different conversations. They use practitioner lead conversation. They use, um, client lead conversation. So practitioner lead conversations, traditional, um, very biomed, biomedical type practice where people ask questions like, you know, you know, how is this affecting your life? You know, tell me about your injury. Tell me about your concerns. Tell me about how, how will you move, your quality of movement. And then the, um, patient led ones are these conversations where, yeah, it's a bit more tell your story, but also when people doing manual therapy, so they might be doing massage or manipulations or mobilizations that conversations just flow and people are getting to know each other. And through this context, that's where clients often express, you know, distress, distress is the main thing that they first start presenting. And sometimes that distress is associated with suicidal thoughts and behaviors. And that's essentially how the, the, the, the, the process emerges. It's not something that's deliberate by physiotherapists. Generally. They're not going out there and actively saying, I'm gonna screen clients for suicidals and behaviors or I'm, or I'm not even gonna directly ask necessarily because that's not their role, or they don't feel that it's their role, but it's that kind more natural process where it emerges.

Dr. Jasmine B. MacDonald (18:13):
So if this is something that comes up, maybe in two to five clients a week, probably more, as you said, that we haven't been able to quantify yet, um, and physios are saying, you know, are not really feeling it's necessarily part of the physiotherapists role to unpack these things, psychological distress, or, um, suicidal thoughts and behaviors. How do they manage that? Or what's the reaction like?

Ryan McGrath (18:39):
A lot of discomfort in terms of a and a lot of boundary tension. So there's not only in my research, but in also a lot of other studies that just look at physios, trying to address psychological factors in physical health problems is that physios feel like, oh, you know, sometimes we feel like we are being psychologists or we're feeling like we're being counselors. We're not, we're not doing that. And we're not trying to be that, but it's this tension that physios are often reporting. And I think that harkens back to the training that physiotherapists get it's grounded in biomedical anatomy, physiology, pharmacology, neuroscience, and it's very much on the body. And that now we're encouraged to ask, you know, questions about what psychological factors are contributing, what social factors are contributing. So that's where the tensions come out with in terms of, you know, role boundaries and, and physios, I think are very, very concerned about themselves and, and where they sit rather than saying, "oh, I'm worried about the psychologists judging me". It's actually worry about other physios judging what I'm doing. And there's quite a lot of debates in physiotherapy practice about, you know, the, the, the changing profession moving away from more hands on approaches to more education and active approaches and exploring psychosocial factors. And there is that debate in tension within the profession at the moment.

Dr. Jasmine B. MacDonald (19:49):
Yeah right. I'm wondering then about the, with their own boundaries, what, what kinds of clients are easier to manage or work with compared to the ones that might be more challenging?

Ryan McGrath (20:00):
There's an interesting study that I found it's published in about 2003, and I think it was in a physiotherapy journal. Um, yeah. Physiotherapy journal by a person called Margaret Potter, I believe. And they talked to about what a difficult client was. So what I'll do is I'll describe what this study called a difficult client. And then I'll describe what, you know, obviously a difficult client is somebody who's, you know, kind of opposite this, or doesn't have these other traits. So by memory, difficult clients, where people who are very frustrated, they don't necessarily listen. They feel very hopelessness. They are helpless. They don't necessarily participate in interventions. So they're not very compliant. They, and there's a few other types of things as well, that loft in, um, oh, this is a horrible term that they use. And it's, it's a period of the research. So it's not the researchers, um, that I'm criticizing here, but it's just the period of, you know, early 2000s physiotherapy research, 'catastrophizes' so you get some...

Dr. Jasmine B. MacDonald (20:55):
Yeah.

New Speaker (20:55):
Yeah. And they're hard clients to manage. The simple client is one who goes, "oh, I've just got a niggle, it's probably gonna get better. I just wanted a bit of help to get over it". And you go, "here's your exercises". And natural healing takes over, they've with confidence and they get back to it. But they're then, and, and you probably see a lot of them in musculoskeletal practice because they're people who, you know, come and see you in private practice. They've got the funds to do it. They've generally, you know, that means they've got, you know, good, um, a social environment. They're not struggling to pay their bills necessarily. There are definitely, we see them, but in private practice, obviously these people have the ability to pay out of pocket. And particularly when Medicare rebates aren't available for first contact, um, consultations, you have to go to a GP to, to get any type of funding. These people recover quite well, but then there's the other coin is that, you know, the ones that get labeled difficult patients are those ones who get, have persistent pain. They're often tried everything, or then they get perceived as not wanting to try anything. You know, they just want to fix, they want to, like the ingrown toe nail thing. They just want the musculoskeletal equivalent. And that's what they get labeled difficult clients. But in reality, that I think reflects a lot of the stress in their life. Um, a lot of lack of self-efficacy and those things like hopelessness, helplessness, they don't necessarily have the tools to be able to get through it. And they don't actually have the literacy because not many people understand the, the true nature of pain being a pain experience and not associated with tissue damage. So these are conversations that we need to try to have, but they're also something that, you know, are very, are difficult conversations I have and something that we are not well trained at at having.

Dr. Jasmine B. MacDonald (22:25):
Mm, for sure. I remember like reading through your findings and reflecting on, you know, physios saying clients that are really clearly unwell, you know, they're really distressed. Those ones are easier to kind of work out what you're supposed to do. And the clients on the, the other end of the spectrum that are, they're kicking along fine. You know, or they're very, they don't have that kind of clear indication of, um, suicidal thoughts and behaviors. Um, but it's really that space in the middle. That's pretty challenging for physios.

Ryan McGrath (23:00):
But that's where the majority of physiotherapists lye, like clients lye. They're either people who recover, they get well quickly. They don't have a lot of psychological factors would call that have, are indicative for long term disability. And then, then, then there's that middle client group. And it really, it extends out to all the way to suicidal thoughts, but we just don't know which ones are here unless they disclose it and are really open with it. Other people who are really struggling in life at the moment they're languishing, they're only surviving. They've got pains dominating their life. They're often can't work anymore. So once you can't work, that means you've got financial stresses and everything is starting to accumulate and put a lot of load on their life. And they're often yeah, getting label difficult patients. And they mostly rely on that middle, that middle space between, you know, kind of like that middle range of distress. And when you have really high suicidal thoughts, the reason why physiotherapists are more confident and, or at least more comfortable in what needs to be done is because physio's less involved. They go, okay, this person is in real danger at the moment. I'm clearly not the person to help with this. Let's try to refer to another health professional. Let's try to, you know, are we talking about calling, you know, mental health Access Line or Lifeline, or calling an ambulance, those type of things, or even saying, you need to, you know, this is something that's obviously significantly concerning you, you need to go and talk to your GP about this. So they're, they're quite clear, but it's the group in between that, you know, they're, they're hopeless, helpless, but they haven't necessarily gone out and said, I I'm having thoughts of so suicide. And that's, that's where it's very, very difficult for physios.

Dr. Jasmine B. MacDonald (24:29):
Mm-hmm, like a sense of uncertainty of not, not really being sure is that what it's about?

Ryan McGrath (24:34):
Uncertainty and complexity in musculoskeletal prac, not just musculoskeletal, but working with people, people are complicated. There's lots of factors involved and that they talk about in, I think it's in all areas of healthcare, but you have research and then you have practice and practice is an art of applying research and the patient in front of you. And, you know, evidence doesn't speak for itself, you have to interpret it and you have to make it contextualize. And it's, it's a whole, it's, it's an art. And that's why it's a challenging. So people are complex anyway. And when you start adding these psychological factors, which are, really psychological factors are involved in everybody, they do sort of, they don't just appear in, um, in people who are distressed, but they become probably larger barriers or a larger contributor to people's pain and disability in a certain group. And that they require addressing. And that's when it becomes really, really difficult. And that's where people feel uncertain. So it's uncertainty in musculoskeletal and physiotherapy practice everywhere. And then that's just exacerbated in this particular domain, which is distress and suicidal thoughts.

Dr. Jasmine B. MacDonald (25:34):
Mm-hmm well, listening to you and talking about, you know, where this appreciation or acceptance of the role of a physio, um, once a client's showing some kind of psychological distress, I'm sitting here and I'm wondering what it's like for you to have conversations with other physios. Maybe you might meet them for the first time. And you're talking about the research that you're doing. What's the general response that you tend to get? Is this like something that's becoming more and more accepted that needs to be looked into? Or is it still like, "Nope, this is not what we do".

Ryan McGrath (26:04):
"I need help". That's, that's the one that I get all the time. And it's really difficult because my research hasn't focused on, like I have ideas. And from my reading of other literature, I have some suggestions that might be able to help, but I've really just started particularly going, "what is your experiences? What are the issues you face?" And then as part of the normal research process, once you identify issues and problems, then you go, "oh, okay, let's try doing this, you know, type of training or this type of approach" and see if that actually works. So I get a lot of people going, "oh, how, how... Please help me". And I'm going, "no, I just really know what you're struggling with". And I have developed things that I find that work for me. And when I get pressed hard enough, I say, "oh, well, I do this", but that's not what we need in, in, in, in, in physiotherapy practice, we need essentially more research and more time spent. And, and a growing body of research is actually exploring how do we navigate this space? So...

Dr. Jasmine B. MacDonald (26:53):
mm.

Ryan McGrath (26:54):
I think that half answers your question.

Dr. Jasmine B. MacDonald (26:56):
Yeah, it absolutely does. And I guess that, you know, we talk about in psychology, that scientist practitioner model, um, that is quite challenging to pull off. And, and I guess that's benefiting you in this context because you are doing this empirical research to find what the issue is, but it sounds like you're really at the beginning of working out what to do about that. Um, as you collect more and more data, so being able to draw on your practical experience and what you do is better than just going "dunno, dunno it all". and you're tentative, as you say, like more research needs to be done, but it's nice to have both of those to compliment each other.

Ryan McGrath (27:30):
Exactly. And I tend to draw on, see, I've got luxury that, um, you know, obviously I've only got personal experiences within one university and two courses with them in a university. So in some ways it helps you go, "oh, look at they physiotherapy and psychology programs." So in, within the university, so I can compare and contrast. And when you talked about the practitioner scientist model of psychology, I find it interesting that even a part of, I'll talk to Charles Sturt, it has a qualitative research subject. So, and also every other subject, like psychology tends to be on my experience, still quite quant heavy. There's a lot of interest in quant research, but there is a still a recognition and support of qualitative research.

Dr. Jasmine B. MacDonald (28:09):
Yeah.

Ryan McGrath (28:10):
Um, critical psychology and those type of areas. But in physiotherapy, qualitative research doesn't even get that much attention at all. It's out there. It's I, and I find it really, really interesting. That's why I probably have lent to that one because there's a bit of a gap in, in the research there, but physios about RCT [randomised control trials]. So we are not necessarily trained as being practitioner scientists, but we're trained to be evidence based practitioners, which means we learn about what type of evidence that we draw on. And we do research subjects, but they're not embedded in each, um, of our subjects because a degree shorter...

Dr. Jasmine B. MacDonald (28:43):
Mm.

Ryan McGrath (28:43):
...you're talking about really doing four years of psychology. And now it's gonna be five with the changes, at least at minimum, to get re to get provisionally registered, and then you're doing your supervision, whereas in physio you're four years and you're fully done. You're fully registered go out on your own. You're right. So we don't often participate in research as much. We just draw on research and I, I think that's a limitation of the profession and that's a limitation of timeframes. Yeah.

Dr. Jasmine B. MacDonald (29:09):
Mm-hmm , yeah. It's really fascinating. Um, because you know, you're saying that the focus tends to be on RCT, so random randomized control trials, and you've adopted, uh, primarily a qualitative approach. This is gonna seem like an obvious question, Ryan, but why?

Ryan McGrath (29:27):
Uh, because essentially you start with a research question, you go, "what do you want to answer?" And then you go and pick methods about that. And I have been very, very fortunate because of my exposure to qual research and my interest. I was very interested in journalism and I see kind of qualitative research of scientific journalism. You're doing many of the same things, different purpose, um, and different background. But I, I see the parallels there. You know, you, you start with a research question and you see what essentially method is most useful answer these questions and quantitative research is still really useful. It, but in essentially in some ways provides crude analyses of large groups of people and it has its own limitations. And I think that's the thing is in physiotherapy, we hold RCTs and not just physiotherapy in, in medicine, in general.

Dr. Jasmine B. MacDonald (30:10):
Yeah. In psychology as well.

Ryan McGrath (30:13):
RCTs are the gold standard. And that you have your tiers of research and you go down from that and qualitative research sacks itself, nicely down the bottom. And when we're drawing on doing evidence based practice, that's where you're meant to go to, except for a lot of RCTs aren't necessarily, you know, all the limitations are necessarily representative of the samples that you're treating anyway. So there's a degree of, you know, lack of context. And then there's also things like, you know, the fact that people look at RCT and quant research and as this objective truth, and "here's the answer and here's how you apply it" actually, that's where the debate's a lot in physio now is there's a lot of physios going, yeah, we live and breathe the research because we've been taught particularly in the last, you know, 20 years be evidence based practitioners. So we just believe research without, you know, particularly quant research without really understanding it or understanding its limitations. And then there's the other group who's now interested in qualitative research, but there's a much smaller group or at least qualitative type practices, understanding human experience. And we have to navigate, you know, the vast majority of the research is quant. There's only small amount of qual research and how do we actually practice as clinicians? How do we draw on this, um, which base?

Dr. Jasmine B. MacDonald (31:25):
Yeah. All right. So you've, um, alluded to this a couple of times, which is the broader interest that you have beyond focusing on physios who have encounters with clients with suicidal thoughts and behaviors, but actually being more broadly interested in psychological distress. Let's unpack that like, what, what does psychological distress look like? And what, what's your plans for future studies?

Ryan McGrath (31:50):
Psychological distress, what does that look like? Depends on who you ask.

Dr. Jasmine B. MacDonald (31:53):
Uhhuh. It's a loaded question.

Ryan McGrath (31:58):
It is. So lots of people have defined psychological stress as purely symptom and anxiety and depression. That's the way it's operationalized. You see lots of surveys that pretty much hit those type of things. And they're pulled from diagnostic criteria and they're, and in some ways these di, diagnostic criteria look at psychological distress, but then they're also designed to give an indication that there might be a diagnosed mental condition that's, you know, that's underlying this, but I look at psychological distress is something much more broad and complicated. We can experience emotions in very different ways. So psychological distress could be, you know, depression, anxiety could be feelings of grief. Rumination. The exciting way of looking at psychological distress is if you kind of ignore, you know, DSM [Diagnostic and Statistical Manual of Mental Disorders] and, um, diagnostic models and go "this person, what, what is the stress?" And the other thing too, it could be anger. So the way that I kind of see distress is, you know, it's, it's person reported. So if somebody says that "I'm not doing very well, I'm really struggling." That's an indication to distress. And then the way they experience it will be individual to them. And of course you can go and list off and rattle off more things like helplessness and hopelessness and rumination and all those type of things that fall under, um, psychological distress. I don't like the term suffering in this definition, but very, very simply, you know, there's one person who decides psychological distress is a state of emotional suffering. So in some ways that's a pretty good indication that it catches a lot of different type of things.

Dr. Jasmine B. MacDonald (33:19):
Yeah. And I think with your research, it's interesting because it's self-reported, but then it's from the perspective of the physiotherapist and then you interpret and work with that.

Ryan McGrath (33:30):
A lot of different layers there, isn't there

Dr. Jasmine B. MacDonald (33:31):
Oh there's layers. Definitely. If you can share what kind of ideas for studies do you have next?

Ryan McGrath (33:36):
So as part of my Ph.D. research, I've essentially, it almost, you could argue, some people might look and go, "oh, you're just doing the same study again", or, you know, a bit bigger and you go "not quite". So suicidal thoughts and behaviors in the past was when I said it was easy to op, operationalize and really talk to clients about, oh, physios about is that, you know, we're talking about referral points. We're going, if somebody's really in distress, I don't think anybody's sitting here and saying physio should be providing psychotherapy for somebody who's having suicidal thoughts. That's pretty clear cut. So when you're having these discussions, but psychological distress is much more complicated than that because it's a spectrum. You can have no psychological distress. You can have very minimal psychological distress and you can have high levels of psychological distress. And there's a few texts that I've read from physiotherapists in Norwegian and some Australia that's really, really telling. So they talk about how really anybody who's experiencing pain is likely to be experiencing psych, you know, essentially psychological distress, psychological distress and pain are intertwined. And one really interesting way of looking at it is this Norwegian text said when somebody comes in and they're in pain, but they're not experiencing any psychological distress that you, you can observe, that's a concern in itself because when you're experiencing pain, it's a stressor, it's an unpleasant experience. It's not a good thing. That's why they've come to see you. And if they don't appear very distressed, then what's going on? What are they suppressing? What are they hiding? What are they, you know, not wanting to share with you.

Dr. Jasmine B. MacDonald (35:00):
Interesting.

Ryan McGrath (35:02):
So as a physio, we work with stress all the time. And then the question is when do we get other people involved? And I, I love this and maybe it's, I, maybe it exists out there, but from what my reading, it's not very common, but this idea of multidisciplinary teams. Yes, they're great. But that's where I look at private practice. And we're just surrounded by lots of more physios or OTs [occupational therapists] or things like that. And you go this whole multidisciplinary team where you can go, "oh, I've got a referral. I'll just send 'em off to somebody". And then I'm from a regional area. So there's often, you know, months of waiting list before you can go and, you know, get that support. So it's really, really tricky because physios are working with people who are really distressed. And I bet you, a lot of them would refer to a psychologist or a counselor or a, um, social worker or anything like that, if they could, but also our funding models don't allow that very simply. So that's where my interest is now looking at the practices and experiences of physiotherapists with clients experiencing psychological stress, because it's much bigger than that. And physios are involved in the management of distress in that way, particularly what people define as pain related distress, which is a complicated topic in itself.

Dr. Jasmine B. MacDonald (36:06):
While you were describing that, it kind of occurred to me that this might be, it might just be that avenue that some certain demographics who aren't likely to present to mental health services are gonna feel a lot more comfortable going in and seeing a physiotherapist and that the distress is gonna be, you know, something as you've said, is intertwined with the experience of pain, but it, for some who would be okay seeing a GP or a health professional, it's easier to step into the door of a physiotherapist than necessarily try to get a referral for a psychologist or see a social worker. Do you think there's much in that that?

Ryan McGrath (36:43):
Is a lot in that, um, particularly, and again, we're talking about pain here. And a part of my research is I really want to explore other areas of physiotherapy practice cause physios work with more than people without pain. They work with people with disability and all these other areas.

Dr. Jasmine B. MacDonald (36:55):
Yeah.

Ryan McGrath (36:55):
So, and they're all stressors, but it, that's why it's all unique that I'm also interested in that. But getting back to pain, pain is something that people often describe as it's happening to them. It's not a part of them it's happening to them. Oh, my foot hurts. It's something separate. It's like, I'm not sure if the listeners would be, um, familiar with, uh, Lorimer Moseley who does Explain Pain. And there's an interesting video where he's describes chronic pain. And then in the imagery, they've got a little dog that's biting at somebody's ankle or their shoulder or their back. And it's this external thing. So it's, it's not a part of you. And that makes it very comfortable for people to come and see a physio because it's not a part of them.

Dr. Jasmine B. MacDonald (37:29):
Mm.

Ryan McGrath (37:29):
And it's just something new. And pain's not something that, uh, in reality, we all experience pain. We all experience pain quite regularly, but we don't experience necessarily problematic pain. Like a lot of people don't necessarily experience problematic pain often. Um, so when it does become problematic, it's something else. They want it cured and they want it fixed. So, and again, a lot of things for some pain treatments, because there's such a, you know, we, we are getting a, um, nociceptic input, which is just a, essentially not a pain signal, but a, you know, sensory information from a joint. So when my partner does a, um, ingrown toenail surgery, there goes that, um, noxious stimuli, there goes that sensory information it's solved. So people think that often back pain can get solved in the same way or shoulder pain can get saved. You know, you know, that's why you have high rates of knee replacements. You go, oh, I've got knee osteoarthritis. It's painful. All I can do is go and get surgery. And we've real that that's not the case, there is psychological factors that are intertwined in all of this.

Dr. Jasmine B. MacDonald (38:23):
Mm-hmm. Yeah. Good points. What aspects of psychology do you think are already being applied, you know, solidly within physiotherapy?

Ryan McGrath (38:33):
Ooh, solidly, I'd say bugger all being applied solidly, but this is a thing is that I think there's a lot of well intentioned physios, and I don't think they're doing harm. They're just trying to do the best that they can. And that's all, all I'm trying to do is when I'm in practice is doing what I can and what I know. So they're drawing on every little bit of literature that they can. So I know that there are physios out there who have, um, some have gone to the extreme. Some have, there's a couple of dual registered psych physios in Australia. I'd love to talk to them. Then there's a couple that have gone off and done quite significant training. I know one that's almost finished their, um, like a postgraduate degree, um, in cognitive behavioral therapy and they get asked questions like, "oh, how are you ever gonna apply back in physio?" So that that's, that's, that's another story. And then there's others that I know that they're looking at as doing low levels CBT [cognitive behavioural therapy]. So I know that there's a New South Wales, mental health group and full of physios. And they're really interested in learning about low level CBT as part of insurances and SIRA [NSW Government State Insurance Regulatory Agency], and then there's physios who are just trying to do their own thing, practice as a normal physio, but are now reading literature and saying, oh, there's things like motivational interviewing that they want to get involved in, or they want to get involved in ACT [Acceptance and Commitment Therapy] type therapies. And those types of, or at least not necessarily into performing these therapies like ACT or CBT, but adopting those principles. And that's where I think physiotherapy approaches such as Explain Pain, which is a physiotherapy, It's a, it's a general pain approach, but predominantly practiced by physios. And it draws on, um, from, I can't recall what area of, uh, psychology it draws from at the moment on top of my head. But I think it draws from, you know, um, you know, like neuroscience and cognitive psychology and then there's cognitive functional therapy which also draw us on cognitive psychology and, and that literature, but also, um, drive like draws heavily on behavioral psychology. And these are kind of physiotherapy approaches that are stealing ideas and practices from, you know, the psychology literature and trying to apply it in, in normal practice and make it contextual with physios, which is a challenge in itself. And they're doing great. I'm really excited to see where they're going, but it is a challenge.

Dr. Jasmine B. MacDonald (40:38):
Mm-hmm, .

Ryan McGrath (40:39):
Like, to invent your own therapy, essentially, it's basing on. And these, these physios who are doing it, they've spent, you know, 20 odd years researching psychosocial factors in, um, low back pain, shoulder pain, plantar heal pain, but they're not nec... They're not trained psychologists.

Dr. Jasmine B. MacDonald (40:55):
Right.

Ryan McGrath (40:56):
And they obviously talk to psychologists and talk to people like that. But it's, yeah, it is a challenge appropriating that when, you know, really you need quite significant training in both to be able to develop some of these therapies.

Dr. Jasmine B. MacDonald (41:07):
Yeah. Sure. Well, what about, um, kind of reflections from your own practice? So you're saying, you know, the, the work that you do with, um, uh, refugees, what do you think your study in psych and, and the things that you're learning through your research add to your kind of daily practice?

Ryan McGrath (41:25):
So the first thing that I find very interesting is that when I was talking about being, you know, what is a physio and I'm talking to people over the phone, so I'm not hands, I'm not doing anything like that. What I've been interested in, it's been really comfortable reading literature and supporting my own practice is that you don't have to confine to the, the stereotype of what a physio has to do. There's different ways of approaching. There's lots of people, you, you find them, it's like Norwegian psychomotor physiotherapy. They encourage, you know, oh, some of them do after somebody has their exercises, that they have a nap in their consult room. I probably shouldn't say this on a recording, but, um, I had a patient and their partner come in a couple weeks ago and we're doing all their, you know, essentially low back pain, doing some, um, lifting exercises, really actually challenging them, seeing what they can lift. And cuz they're very fear avoidant, didn't want to bend in their back. Didn't wanna do anything like that. So we started off with some low weights and see if you can bend and twists. And I had a heart attack when she went down and grabbed a much heavier weight than I expected cuz I had a whole range of 'em and I was gonna go one through one to one to get up to 25 or 30 kilos. And she just went to the, the 30 after doing the first two herself and was fine and had many heart attack then. But so it shows also my own, um, beliefs about, you know, I know the spine's not fragile, or the low backs fragile, but I still get scared.

Dr. Jasmine B. MacDonald (42:39):
Mm.

Ryan McGrath (42:39):
And she did all these exercises and she did really, really great. And she felt like she got a lot of confidence, but naturally after picking up all those weights for like for about half an hour, she was a bit sore. So while I was seeing her husband in the gym, she just popped back and I said, oh, just have a relax here's here's the plinth. And turned off the light cuz she was just comfortable there. And obviously she's um, looking after her kids, I think she's got quite a number of kids and she's got all those stressors in her life. So we turned off the light. I found a random blanket in the back and let her, and she had a nap while I then did the next, um, 45 minute consult with her husband out in the gym, looking at his issue. So, and then she came back and when we flipped on the light, we knocked and flipped on the light and she came out and she was feeling much well rested and no longer stiff and sore. And she was ready to tackle the rest of her day. Cause I'd been talking to her earlier about, it's important to do more exercise, more movement, get, you know, really get some confidence in your lower back. But you're also running ragged looking after all your kids. You're telling me that you're at 110% all day and I'm not gonna say here, you know, don't do all of that cause that, you know, that's in reality. How do you, how do you reduce that significantly when you actually are a care provider?

Dr. Jasmine B. MacDonald (43:44):
Mm.

Ryan McGrath (43:45):
But what I was trying to iterate is try to run at 95%, give yourself that little bit of time, that little bit of self care, that little bit, you know, don't hold yourself. If you do cooking at 6:30 at every night, if you're 15 minutes late that's okay, don't, don't put yourself in this stress, this anxiety state all day where you're running ragged, time yourself. So that, that was the reason why she's done all this exercise, go and do some self care, just relax, you know, do some gentle movements in there if you want, have a nap, whatever you wanna do and then carry on with the rest of your day. So I would've never had the confidence to do something, to let a patient literally have a nap in my consult room. If I hadn't been reading these approaches from Norwegian psychomotor physiotherapy. Oh. And the other part was that I sort, uh, I ended up sword fighting with the, um, it was a very odd consult. Actually. Those two, I was probably, normally my consults are a little bit more typical physio, but these ones were a bit bizarre, but he's out there. So he's talking to me about, he's had shoulder pain for a significant amount of time and then he doesn't want, like, he doesn't find the motivation to participate in exercise. Like in, in therapeutic type exercise, he goes to the gym. He's quite strong, quite, you know, when I do all thing, muscle testing and everything like that is really, really good, but he still experiences persistent pain. And so I've given him exercise in the past and he doesn't really do them cuz he doesn't feel that they're meaningful and they've been similar to ones he's done before. I go and talk about cuz there's a few physios talking about drawing on psychology, like mindfulness and meditation and those type of things. So he's done that in the past and that's something that, you know, physios tend to do with clients when they're really in these anxiety states or they're really worried about moving and you got a lot of this is actually to calm yourself down, move freely. Don't really tense your core muscles and everything like that.

Ryan McGrath (45:26):
Because often when you're in pain, everything kind of jars up and you don't wanna move goes into hyper protective mode, but he's already done that. So I'm going, what do I do? He's you know, I'm running outta things here and he's not doing exercises, so how can we get him to do the exercises? So he's got a big fam... Like of course he's got a big family and he loves playing with his kids. So I'm going, how do we get you actually to move and enjoy and actually do it regularly? So we ended up prescribing, we, we played with sticks for a while and we were sword fighting because as part of sword fighting, he was twisting, moving, flexing, moving with purpose and enjoying himself. So his essentially exercises for the next couple weeks is to go home and go to Big W or Kmart and buy a styrofoam sword and go and play with his daughters and get moving and do that type of exercise. Cause you don't need specific exercises for low back pain. You don't have to be doing joint specific exercises. You can do things that are meaningful and that are interesting and they're, you know, more general and that can really help too. So yeah.

Dr. Jasmine B. MacDonald (46:21):
Yeah.

Ryan McGrath (46:21):
Went from his, wife's had a nap and he's sword fighting. So I dunno what they think physiotherapy is so...

Dr. Jasmine B. MacDonald (46:28):
But that integrating movement and therapy into every day life, instead of it having to be something completely separate or um, you know, serious and repetitive, I think is really interesting cuz it it's actually tying really broadly back to psychology with the work that you do in terms of with her in this context, it was about confidence. Um, and the, you know, the cognition around that and with him it's motivation...

Ryan McGrath (46:54):
Yep.

Dr. Jasmine B. MacDonald (46:54):
So comes back to you saying earlier about, you know, the influence of motivational interviewing of, well, why, why are you here? You know, you're here because you want something to be different. Um, but we all struggle with motivation. So weighing up the, you know, what are the pros and cons of doing different therapies or tricking him into therapy playing like sword fighting with his kids, I think is fantastic.

Ryan McGrath (47:17):
But it was also very candid. This is the thing that I've drawn on. You know, the psychology type literature is that you explore, you do case formulation. So you get to know more of their story and what, what their strengths are, their weaknesses are and what, what their goals and aspirations are. And physios are trying to do this. But you know, when you draw on what psychology is, it's, you know, you guys have been doing that, like psychology has been doing that for many, many years. This is not new stuff. So when, as a physio I'm going, okay, my main mission for this consult, I don't need to do any manual therapy. I don't need to, I need to find a way that he can do some of these exercises, which we know will help him. But we have to find a way that, yeah, obviously, as you're saying that he's motivated do it and will enjoy doing it because the other thing is when you have these things that you're enjoying in your life that improves these, what they call is safety messages. Like you can move and you can move and not have paint. And what was amazing with him. And he actually was, you know, in this conversation saying when I do shoulder flexion with a weight in my hand, I'm focused. I just think about my shoulder. I think about it. And I can't stop thinking about it. I feel really tense. So I stop breathing and we've tried to do relaxed breathing and that's helped a bit, but he's still fixated on that joint. But when you get into do something more meaningful, something more general. He doesn't think about his shoulder. So he was moving freely with no pain or very little pain when he is sore fighting. But when he is doing a specific exercise where he is focusing and that's, so that's type of distraction therapy and what also we're doing is behavioral experiment. So we're seeing what type of things. So we put in a different context, different environment. How do you, how do you actually, how do you go, how does this affect your pain?

Dr. Jasmine B. MacDonald (48:47):
Yeah. It builds up that self-efficacy, if you can point that and go look what you're doing, this doesn't match the schema that you have of what your shoulders like. Yeah.

Ryan McGrath (48:56):
Expectation violation. Exactly. And that's what we try to do is that we, you know, ask people what things can you do and, and go, oh, there's a little bit of, and you don't tell 'em, it's not a lecture process. You go, you, you told me you don't have pain here, you know, for, if you have somebody who gets into a hot pool and they see, oh, they can move freely. And then somebody who says, and they don't have any pain. And then you have somebody who has pain, like all the other times, like, you know, in cold weather or when they're outside of water, you say, so there is a situation that you can experiencing, you know, low levels of pain that probably points to something, not being structurally wrong with your back.

Dr. Jasmine B. MacDonald (49:30):
Mm-hmm .

Ryan McGrath (49:30):
We are dealing with the cognitions, we're dealing with a lot of, um, emotions involved with this in terms of the distress and the catastrophization and fear. And then we're dealing with a lot of like even social factors involves. And that comes down to a lot of my clients at the refugee health clinic have client, you know, obviously they're coming from backgrounds that have, you know, been associated with a lot of stress, they've got a lot of disruption. And they have difficulty engaging with the healthcare system because of language barriers. So they have all that challenge as well.

Dr. Jasmine B. MacDonald (49:59):
Yeah. Right. For sure. I think any work that, um, endeavors to bring various disciplines together and encourage eclecticism of drawing on the strengths of different approaches, I think is only a good thing. So, um, yeah, just really appreciate you having a chat and sharing all your insights. If listeners want to keep in touch or see what you're working on next, what's the best way for them to do that?

Ryan McGrath (50:24):
The best way for anybody to get in contact with me would probably to look up Ryan L McGrath at Charles Sturt University. You'll see my, um, research output and that'll have an email address there. Um, I have two, I have a staff one which is rmcgrath@csu.edu.au, and then, uh, Gmail at ryanlachlanmcgrath@gmail.com. So either one of those ones is fine. I really encourage people to reach out. I love having these type conversations. And the other thing too, which I didn't get to mention is that I'm sitting here stealing all this psychology. I feel like I'm sitting here, I'm going reading the literature and going yoink, yoink, yoink, yoink. But I think it's really important that we do the, uh, the, um, inverse cause I, I talk to a lot of, particularly, um, from my understanding psychologists aren't necessarily comfortable with working with persistent pain or chronic pain because it's not a large part of people presenting to them. And similarly, I've spoken like this is, this is something I know for sure is a lot of social workers who work with people and provide trauma counseling and those type of things, pain's something that's that scares them because it could be something biomedical. It could be something scary. So I encourage people that we also, you know, physios need to give away our knowledges of the biological and biomechanical. So it should be a bit more of a reciprocal relationship rather than going "I'll just steal what you guys do and give nothing back and become", you know, and fill that middle space. We need more practitioners getting involved with people who have both, you know, physical health and mental health challenges and issues that they're facing.

Dr. Jasmine B. MacDonald (51:50):
Mm. I think that's a really important sentiment. So I'm glad that you added that. And when you're saying that, I start to think about from a psychological perspective, probably some of the people that we might see when they have chronic pain are also presenting with some kind of substance use, not always, but that can be a factor as well, which further complicates things and sometimes means, you know, um, a bit of a juggle of what service needs to be involved if you only focus on mental health as opposed to substances. So...

Ryan McGrath (52:17):
Exactly.

Dr. Jasmine B. MacDonald (52:18):
Yeah. There's a lot to factor in there, but that idea of drawing in and learning from both and not just, you know, some reciprocal stealing sounds sounds ideal.

Ryan McGrath (52:29):
Exactly.

Dr. Jasmine B. MacDonald (52:30):
Amazing, Ryan thanks so much for coming and having a chat. Um, the work that you're doing is super fascinating and I'm very confident the listeners will have enjoyed hearing your insights and, and the things that you're working on. So thanks a lot.

Ryan McGrath (52:42):
No worries. Thank you for having me.

Dr. Jasmine B. MacDonald (52:46):
For those of you at home, that's all for today. Show notes for the episode can be found at www.psychattack.com. If you've enjoyed listening to Psych Attack, please rate it on your favorite podcast platform and share this episode to help other people find the show. If you have questions or feedback, you can reach out on Twitter [or Facebook]: @PsychAttackCast. Thanks for listening and we'll catch up with you again next time.