The Complexity of Suicide: Beyond the Myths with Dr. Jill Harkavy-Friedman

Dan is joined by Dr. Jill Harkavy-Friedman, Senior Vice President of the American Foundation for Suicide Prevention.

Dan and Dr. Harkavy-Friedman discuss the complexities surrounding suicide, and the stigma that has historically hindered open discussions. Dr. Harkavy-Friedman highlights the role of the American Foundation for Suicide Prevention (AFSP) in advancing research and advocacy, the challenges of addressing gambling disorders in relation to suicide, and the importance of community engagement in prevention efforts.

The American Foundation for Suicide Prevention is dedicated to saving lives and bringing hope to those affected by suicide, including those who have experienced a loss. AFSP creates a culture that’s smart about mental health through public education and community programs, develops suicide prevention through research and advocacy, and provides support for those affected by suicide.

AFSP is the largest private funder of suicide prevention research, dedicated to understanding suicide and identifying evidence-informed strategies to help save lives. Researchers can explore its priority areas and grant application process by visiting afsp.org/research.

Learn more about AFSP in its latest Annual Report and join the conversation on suicide prevention by following AFSP on Facebook, Twitter, Instagram, YouTube and

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Chapters

• 0:00 Introduction and Episode Overview
• 6:12 Early Teen Suicide Study and Impact
• 9:40 Overcoming Stigma and Misconceptions About Suicide
• 13:35 Evolution of Suicide Prevention Research
• 17:18 Transition to the American Foundation for Suicide Prevention (AFSP)
• 25:11 Gambling and Suicide: Emerging Risks and Research
• 30:07 AFSP’s Unique Role in Suicide Prevention
• 33:45 Setting Research Priorities at AFSP
• 37:05 Community Engagement and Advocacy,

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 45 of psychotherapy and applied psychology. Who we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. You find the show interesting, it'd be much appreciated if you shared it with someone you know might enjoy it too. It's a great way to spread the word and keep the conversation going. Today's episode's a little different from what we normally do here at psychotherapy and applied psychology. Today I'm speaking with someone who holds a different kind of role. As the vice president of research at the American Foundation for Suicide Prevention, she has a bird's eye view of what's happening, what's gaining traction, what's being funded, and what policy advocacy actually looks like. But it was a great opportunity to learn from a different perspective and I absolutely loved where this conversation went. My guest is the vice president of research at the American Foundation for Suicide Prevention, where she leads the research program, funding grants, offering workshops, and disseminating findings to raise awareness and support advocacy. She's been a clinician researcher for over 35 years, has published over our 100 peer reviewed articles and trains clinicians nationwide. She joined the American Foundation for Suicide Prevention in 2011 and is an associate professor at Columbia University while maintaining her clinical practice in Manhattan. I also want to give a quick shout out to Trish over at AFSP for helping us put together this conversation. In part one of our conversation we discuss Stigman Suicide, the evolution of suicide prevention research, transitioning into the nonprofit world, gambling in suicide, and much more. This episode begins with my guest talking about how she got into studying suicide. So without further ado, it is my pleasure to welcome my very special guest, Dr. Jill Harkavi Friedman. Actually, my entry into suicide research and clinical work was, I was in the right place at the right time and or maybe the wrong time because it was 1985 and I got my first job at a graduate school and my chairperson wanted somebody to study teen suicide and to start a clinical work. Well, in 1985 you weren't even supposed to say the word suicide because without understanding it all the thought was if you say it you can make somebody suicidal, which as we know now from all the research is absolutely the opposite, which is when you talk about it you can actually help somebody. So he had been trying for a few years and nobody would do it and I came along and said I'll do it and honestly that's how I got into the field. At the same time a high school student who wanted to do a project came to me and she wanted to look at suicidal ideation behavior in her school and the principal was concerned about it and also wanted to look at it. So we developed a survey which is now in existence since 1989 published in existence longer and we surveyed her school thinking maybe we'll get one or two kids who made an attempt. Well of 383 people about 9% of the kids reported that they had made an attempt and they gave us full details about what they had done, why they had done it, what happened afterwards and we learned about how it's kind of like the youth behavior risk survey now. We learned about if they thought about it did they have a plan, did it stick with them and it raised the issue of teen suicide in a time where it was just starting to be studied. So it was really the first study that would with data public about suicidal thoughts of behavior in high school students and then I used those data we replicated it three years in a row and was able to get some money from a foundation to start an adolescent depression and suicide program and that program when I said I want to call it the adolescent depression and suicide program they said you can't put suicide in the title. I'm just giving you a frame of reference and I said well not everybody who's depressed is suicidal and not everybody who's suicidal is depressed so how are they going to know where to go. So I'm happy to say the clinic is still in existence and this is training site for psychologist psychiatrists at Montepier Medical Center so that's how I got into the field that's a long story. So you're saying that because not everybody that folks who are suicidal if you didn't have suicide in the name how are they going to know that this can help. That's right that's right and also we also not being afraid to say the word because suicide is more complex than that but there wasn't a lot of research at the time and the one study that suggested you shouldn't say it was if anybody read the study everybody quoted it but they didn't actually read the study what the study had done is they had interviewed 14 boys who had made suicide attempts and asked them do you think people would be uncomfortable if you talked about it and that's how everybody got to don't talk about it. Wow that's fascinating I didn't realize that I never really I don't know I guess because I'm of an age where it was I mean there's still a stigma and that sort of thing but you know going to graduate school and you know psychology and stuff it's just people just talk about it right it's not a but I didn't realize that was sort of where that belief started I guess. Yeah I used to describe it as I was once at a wedding where the bride made all the women line up and she turned around and threw the bouquet and we all step back and it fell on the floor well that's what suicide prevention was like it was really there wasn't much study of it there was some biological studies starting in the 70s and really though that research is what led to the development of the American Foundation for Suicide Prevention some researchers and some people who lost people to suicide in 1987 got together and said we need to know more about this and we need to fund research is that's the only way we're going to learn about it and that is really where the fields came from. I still think about like how many people how I've I've no doubt that some reason that that there would be more suicide research if there wasn't as much pushback from you know people places like where I experience it is like from our from our IRB from our ethics board it's like if I have those magic words in there it's going to be so much more of a pain in the ass to get it through like it just is and it is and you know farming you know I'm well armed you know with data to say yeah this is and I have good collaborators here you know David Klonski he's been super supportive of me and helping me and getting me stuff through but like I wonder about you know how much how much further along we would be an understanding and helping and being beneficial if there wasn't that sort of like you know that sort of reaction from the powers that be right and that's because of what I think because of a lack of understanding about suicide you know suicide is complex it's not caused by one thing there are many factors that might increase a person's risk at a particular point in time in the face of maybe some long-term or short-term stressors and then if you have access to a lethal means then you could die by suicide like that's a complicated process it can happen fast in a person at risk but it's still a complicated process and people really think if you're thinking about it then you're at risk and we know that's not the case most people who think about it never act on it and they may even just have a fleeting thought of it and even people who make attempts 90% of them will not die by suicide so we have to get away from that knee jerk response oh someone says they're thinking of it they're at risk to die because it's not accurate and so educating IRBs and people in schools and hospitals about when you hear that have a conversation and get to know what the person is thinking understand what the contributors are and ask about them and that's what's got to change I myself for AFSP then a lot of time presenting a conference is where I stand up and say with 30% of people with mental health conditions thinking about suicide some point in their life excluding people with suicidal behavior means that we end up with treatments that don't work very well and if we include them that's how we are going to learn how to save lives if imagine if they said oh for cancer treatment but we can't do this because somebody might die of cancer well of course you can guarantee that somebody's going to die whereas if you look at all the suicide research it's very rare for it to happen it happens but it's usually has nothing to do with the study it has to do with something going on at a person of risk at that point in their life and so that whole attitude really we need to change that and that's also what's behind developing crisis services now that not everybody needs to be hospitalized you know that most people get through a period of risk pretty quickly doesn't mean they're never going to be in another period of risk it just means that most people are appreciate whether they didn't die by suicide and they're glad that they're still alive so why don't we get how did you first get affiliated with AFSP with Bergen Foundation for Suicide Prevention? So I got my first grant from it was then called the American Suicide Foundation but we quickly learned you had to put prevention in there it's a different audience and I got my first grant from them in 1992 to study suicidal behavior and people with schizophrenia and I've been working with them forever you know ever since but I came on staff July 11th in to I mean yeah July 10th in 2011 so I've been here since 2011 on staff but I worked in many projects with them I was a scientific advisor and I took the position because I still feel that what AFSP does is well informed well intentioned and effective or potentially effective like they just do they may take some time to get it to the public but we do really sound work and it when we say something it's coming from a place of caring but also evidence-based and so I still love it I came here I was 55 years old when I changed jobs from Colombia huh so I mean how did that I'm sort of curious for you personally because I mean that's a you know to go into this you know into this role as you know senior vice president of research that that's a huge transition right I mean that's a very that's a big job like what was that you know how how was that approached what was that what was that experience like for you well they approached me because they knew me and they wanted to change their research at the time they had somebody who was sort of the halftime running the research program and they really want to develop a research program not just a grants program now I was at Colombia for 21 years before I came here and Alborancy College of Medicine Montefur for five before that so I was deep into my career at that point and what I did at Columbia was I worked with two different groups uh who actually didn't overlap at all one was the schizophrenia research group and one eventually was the suicide research group when they came many years after I was there and what I what I've always liked to do is consult to others so they can do their work so I did have an RO1 I did have an um you know a federal grant but I found that I prefer to support other people's grants and so I became the head of diagnosis and assessment for one grant and the associate director for the other area and I was teaching research at methodology uh and I used to call low level statistics for high level people for all of the t32 fellows in the Department of Psychiatry at Columbia. What's a t32 fellow? So a t32 fellowship is a university or hospital gets a grant to bring a group of fellows in and educate them in their topic so we had a fellowship on um on substance use disorder we had an affective disorder schizophrenia fellowship and we had a child fellowship and so I it might work there if they all sat in one room together and taught them research design and methodology so um so I actually had the research back where I had been in the field for many years so I knew many of the researchers who presenting and well published at that point and so it wasn't that big a leap the bigger leap was moving from a state hospital where I had to wait for pencils to being in a place where you could have the basics that you needed to do the work you needed to do and so it seems like a small thing but when your New York State Psychiatric Institute was a great place they had so many ways so much research going on um but it was a big shift and it turned out to be great it I have the opportunity to impact the research the people the people who are affected by suicide I've discovered I love to talk about suicide endlessly um and really motivate people in train clinicians so like I said I did not expect to change positions at 55 you know but it turned out to be great and it's such a great place so that's that's part of the why so what's a day in the life of a vice president of research like well I can only speak for myself but um I think this is that I like it so much because I joke I say I'm a Gemini you know Gemini's like to do a lot of different things at once and so in addition to doing this podcast with you and you are an AFSP researcher so I've been able to both help your not help your application across but follow your application advise about research or methodology and now that you had a grant then help I read every progress report and what you're doing we share the publications so when I came here my goal was to not just have a grants program but also to have a research researcher education program and to educate the public about what we're finding in research frankly it's very nice to give a talk to your peers but even better is having an impact on people's understanding and behavior about suicide prevention and so we're we're in that domain those domains now so we have our grants program is very robust we funded seven they have million dollars worth of new research last year 34 new studies we have webinars for researchers to both career development as well as topical areas and you can actually go to our website and read watch them look at the slides are there we also have been disseminating research through social media and traditional media and so so fun like having tick-tocks about suicide prevention and it's from July to January we had 4.5 million impressions about what we're learning from suicide research so so my day might be going over a new tick-tock developing a webinar for researchers right today I'm reviewing grant applications not reviewing but assigning reviewers because I don't have a vote in the in the actual giving of scores and grants I get to talk to researchers about their work and advise them about what they want to study and you know I get all these calls like do you think I should do this do you think I would the funny thing is they say what is AFSP interested in and I always say AFSP is interested in preventing suicide in any research that's going to be innovative and potentially impactful and is methodologically sound and so I spend a lot of time talking to people applying we actually give feedback to every applicant if they don't get the grant and so I also end up speaking to people about their feedback if they don't understand something for how they can make their grant better because we allow for up to two resubmissions you know in the nonprofit world usually you apply for a grant you get a yes or no and that's it but our goal is to develop the field in the research community so I might do that we might have a call about our upcoming coming international summit for suicide research that we partner with international academy for suicide research on I also today did it in service for our staff on gambling and suicide an update so that was this morning and that's kind of what it's like you know we are our goal is to prevent suicide to develop research advocacy education and support for people affected by suicide and that's what I get to do every day so I have to I have to sort of just there's a lot of things you said a lot of places we could go I feel like you just hit on the gambling in suicide thing and I know nothing about it but I was just talking to one of my students who's doing her internship at a VA and we were just we were talking about it and what she was seeing sort of boots on the ground is it could you give us just a this maybe a little unfair but could you give us a thumbnail of like big picture where are we with gambling in suicide well you know it's like many things in suicide when you have a gambling disorder you there's there is there's not a lot of data so these are going to be gross generalizations and not firm but it does look like people with gambling disorder have a higher rate of suicide than the general population more than people with anxiety disorders depression mood disorders less than people with substance disorders major depression bipolar disorder and psychosis which is what we find with so many things if you look at eating disorders it's the same thing it's the combination of eating disorders with one of those four usually mood disorder substance use psychosis same thing with PTSD so it's that multi-determined nature that if a person has other factors like in addition to a mental health condition if they have a history of sexual or physical abuse if they have a chronic health condition if they have a head injury other comorbid mental health conditions then that may increase the potential in the context of stress like financial difficulties and which you know gambling disorders cause financial difficulties relationship problems intimate partner problems work and social problems so those can precipitate shame and also indebtedness which makes it hard for somebody to get help so the bottom line is a person who has a gambling disorder and other risk factors pursues like may have an increased risk but it's a it's a sign that you need to have a conversation with them talk to them find out how they're doing and help get help get them to resources it doesn't mean it's not a straight line but it's something to look for and then and we have all kinds of guides online like how to have a real convo and videos we have the talk away the dark campaign public service campaign so we offer many opportunities to learn how to have that conversation and what to do but it's not it's a way to reach people in a particular group like people who are struggling with gambling disorders and help them learn and their people who care about them to learn about suicide suicide prevention yeah you know I it seems so like when you sort of sit back and think about it maybe when I've sat back and thought about it really think about so now with so much sports gambling legalization in the US that I could be you know gambling like crazy on my phone and my loved ones they will have no idea right or they think I'm doing it just a little bit but then all of a sudden right it just sort of like keeps you know there's a snowball and I can go down this rabbit hole and I'm embarrassed and there's right I mean I I would be and then you could just see how isolating that would be and just sort of this shame yeah absolutely you know there were pros to gambling obviously most people who gamble are not going to be at risk for suicide 85 percent of people have have so gambling means gambling betting gaming it's there has to be that you invest something like you wait for something there's a risk and it's really uncontrollable and then there has to be a prize at the end that's what makes it gambling so playing bingo you know in your community center for fun is not gambling playing bingo for money is gambling so what they're pros to gambling it's fun and exciting it's thrilling it raises a lot of money and a lot of different industries it creates 1.8 million jobs you know and so there are pros to it but that's fine for somebody who isn't at risk for gambling disorder and it's a disorder because it is disruptive and impairing so there are also cons mostly the shame the indebtedness and all the ancillary problems that come along with that so sports betting by the way just started legally in 2018 and it's in 38 states actively 48 all told have was on that are coming on the books if they're not already so it's it's it's also true that having a little tiny sentence at the bottom that says if you're having help with gambling contact it's not enough it's just not enough we need to raise it to the surface because even if you have terrible gambling debt that shouldn't be life-threatening it should just be debt that you can work your way through yeah yeah it's going to be fascinating to see where we where this sort of goes over the next several years but I mean and also thinking about you know if if I'm doing sports gambling on my phone or other gambling on my phone that like how that just sort of again it's just so easy to do it in isolation away from everybody right and sort of like the pros that you're talking about which I think is really reasonable that if I'm doing it on my you know that one of the pros is that there's this social or communal aspect of it right if I go to you know bingo and even if it's you know even if I lose money on it even that there's still this other experience that can be valuable you know socially adaptive and helpful but if I'm doing it in isolation but anyway I just think that that's that's great that you all are doing that work and sort of getting out I don't know about ahead of it but I don't think there's a way to get ahead of this thing but anyway well you know one of the things we're doing is so we did the research we need more research so we will if we get you know innovative and pack full solid applications we're likely to fund it I'll be doing a congressional briefing on the hill at the end of March about it and we're going to get the ball rolling because right now there isn't a lot so part of our work is to be a catalyst to get things moving in the area of suicide prevention and to welcome you know even specific communities and populations into the work of suicide prevention and also people who've lost someone to suicide and gambling was a precipitate you know that opens the door for them so how do you think about AFSP how do you think about the role of AFSP and sort of maybe the unique role relative to other suicide prevention organizations like the niche that AFSP well one thing I will say about AFSP and I don't know if you know this but we have our out of the darkness community walks and I believe that that has put a face on suicide so that not only do people who go to the walk feel relief community and hope but it's also changed the conversation like people can't believe you're out walking for suicide prevention and so that's one thing that I just I think we've changed the whole conversation just by being public and being available we also we also you know our research is very unique with the largest private funder of suicide prevention research and honestly other private funders may find a couple studies here or there but it's not their niche so funding research is really something that says this apart our advocacy arm we have advocacy office in DC and we've started and now implement every year and mental health advocacy days in all states we're in all 50 states now in Puerto Rico and so now there are advocacy days in all those states we also have online advocacy you can sign up just go there to our advocacy center and all you need to do is put your name in an address and and if there's an issue that's coming in front of either state or federal legislature you'll get an email you can sign it and send it or you could write a little part of course I always write something I swear it but but sometimes I'm like too busy and I just push send you know after confess and we know with legislators if they hear from people then they will gather more information and that's how we got 988 we just you know flooded them with with requests for 98 so I think our whole advocacy arm is is unique and a niche and then with our programs we are really we have a general talk saves lives which is a public education program about suicide and suicide prevention and we have 73 chapters that's also unique the in communities so the chapters go and deliver the programs to their communities and now we have a few adaptations we have let save lives which is suicide prevention for the black community and we have talk saves lives for the Latinx community and we'll grow more programs we're working with the construction industry we have a grant with a agreement with Vectel so we're going to bring it so I think that capacity to take the evidence turn it into programs and then deliver those programs is very unique and we're a nonprofit we're not doing it for the money we're doing it to save lives I have to say just listening to you describe all of this I'm getting overwhelmed it's a lot like it's a website when people come to our website afsp.org you know I tell them coming with your specific question there's an answer there but then come back and take a dive into another area and then dive into another area and learn about what you can do to help save lives yeah so how does afsp so afsp has priority areas right and there might be a different language that you use so please feel free to correct me but how does afsp like what's that process like for deciding on what those priority areas are and what they're not right because you can't do everything and you have to let go of some things that are important I'm just I'm just curious about what that process is like yeah so there are different priorities in different areas I mean overall we have our core values which you can read about and our mission which is to save lives and bring hope to those affected by suicide and so I mean on the grand scale our priorities for research education advocacy and support for people affected by suicide so that's like everything yeah that's so much but in research so and well we're in the middle of our strategic planning process so we have a three-year strategic plan we're coming to the end of it it is a big process our board members we we survey our chapters and our staff and our board comes together we have a strategic planning committee and and we draft a plan and then we redraft it redraft it so that's our organizational plan and when we have our current plan is on the website and you can read it and then there's strategies about how we can we get there for everything so that's the sort of grand what are we going to do at afsp and you may know that one of the areas that's been an area interest for us is also reducing firearm suicides because that's something that we can actually do you know it's it's it's actionable and so we've been working with the firearm owning community on that but it really hard work unless you really hard work you know the problem the thing is it's it's not as hard when you have a conversation and people don't actually it's pretty unusual for someone to buy a gun to kill themselves it happens obviously but most people don't buy their gun for killing themselves a lot of people buy because they think they're going to protect themselves we know that doesn't really work but so they don't make the connection between having a gun in a home and increase in the risk in your home for somebody dying by suicide threefold so part of it is really helping to teach people to understand that there are times that you probably want to take that gun out of the home oh and by the way the average number of guns is five at home so it's not that easy or at least engage in safe storage and we try to help people understand that and make those connections but you asked about priorities and the research priorities are set by our scientific council and we set research priorities every two years although we might extend them like we have recently and we look for areas where there are gaps in the research so that we can stimulate research that's our goal to stimulate new research and so all these types of scientists and suicide prevention get together we talk about what we don't know and then we set priorities and narrow it down to two or three so our current priorities are research about or by people from ethnic and racially underrepresented communities research about communities that have higher rates of suicide than it's expected like the LGBTQ community the construction community foster care whatever the researcher has identified and then anything about surviving or survivors of suicide loss because we want to stimulate research in those areas however we'll fund any kind of research it just means that if you're if a grant in those areas is going against another grant for funding we would err towards the priority but truth is we we haven't had that problem we could fund both so but it's really to stimulate new research and so we've had other topics like alcohol, substance use and opioids primary care um firearms you know many areas where there wasn't any research and it's done a great job of stimulating the research community to start studying those areas right yeah I mean for listeners you know my experience has been you know whenever you do any these sort of these adjudications or anything if there are some priority areas or that sort of thing it's like on the rubric that say the rubric is worth 50 points that five points are given to how close is this to a priority area so it sort of like gives you a few extra points if you're really bang on with the priority area but it doesn't exclude you or anything it just sort of gives you a little leg up if your study is neck and neck with another study oh is that how you guys do it so it's really it's really like that's after everything is done and all the scoring and all the whatever then it's basically a tiebreaker right but because we've stimulated the research like if you submitted a grant then we've stimulated that application and if it's a good application we want to fund it um and so far we haven't had to make a choice between that and something else because we've had the money from our walks and our donors to fund research I mean it literally comes from people walking or raising money or donors that's it that's where our money comes from so on the flip side if somebody has a grant from us and they're struggling I will remind them that people walk for this money and so it's it is a motivator and a lot of our researchers end up we would never ask them to raise money or anything but they come to the walks to be a part of the community we have also a research connection program right so where you can speak with the community about your work and I think you've done research connection program and I don't know what your experience was oh it's great I mean it's so it's you know it's so interesting and it's I mean it's so challenging for those of us who I mean I'm getting better at it but you know I just like you said right at the outset which is you know it's nice to talk to your peers but it's also great to talk to people in the community or others and because when you talk to your peers it's like the amount that you might teach them that you might influence the is relatively small because you're baseline you know relatively right and all various but but when you get out there in the real world it's like it's huge because you know because it's just like anything right we have you know you and I know nothing about lots and lots of things and misunderstandings of lots and lots of things that we do and so the community doesn't and so the ability to sort of take people from not just not knowing much but having very substantial misunderstandings of things and just to try to you know erase some of those so you can have you know the impact can be great but it's very intimidating because it's like you know because your audience is so varied right and it's like I want to try to meet these people where they are I but I don't know where they are so it's it's it's but yeah it's very rewarding and researchers often learn from the community what's important or what the real questions are I I have the opinion that people can learn if we offer them appropriate opportunities to do so so we you know if we speak about things in a language it's understandable and not you know high you know hyper academic or anything then most people at some point will be able to understand like I think our audience is and they want to so I you know I always come from I've learned that my four words the guide me are compassion respect patients and persistence and so I find that if I am compassionate towards the audience and I respect their ability to learn and understand and then I'm just patient and persistent then the message will get there and and I find that with everything in life which is why I go to all these meetings saying you have to include people with suicide or behavior in your research that takes a lot of patience persistence yeah I want to think with you know with people in the community you know when dealing with suicide just naturally the question comes up when you loot when somebody's lost when somebody dies by suicide or even attempts to write it's why and how did this happen how did I not see this coming how did I write all those questions I mean I'll be you know to be honest when you know I've lost people to suicide it's the exact same thing I still like even though I know so much about it I still have that exact same you know but I can over time and with you know talking with people in my circle who do have a lot of knowledge like I can get some you know at least what I think is understanding it's some clarity and some closure but if you don't have you know that you know you you want it and so you know get so I think talking to people in the community you know even if it's not necessarily about their specific experience just helping them understand generally what could be going on for folks can be tremendously healing yeah and and there is no there's no specific real answer to why right you could kind of learn what led up to it but what made somebody feel that they had no other options is very hard to understand because in reality there's always other options and so I once I worked with somebody who made it a very serious suicide once and we were talking about it and it was like yeah but at the time it made sense I you know it was a decision and I said it was a decision made on faulty premises and you know a couple months later he came back to me and he said I was thinking about what you said and it's so true and I was like oh gosh what did I say but and that's what he said you said it was a decision based on faulty premises and that's true in his case he had a medical problem that was undiagnosed that so he didn't have any cortisol and so his brain was not functioning properly anyway and when he got treatment for his medical condition he he could never understand why he did it that turned out he had no cortisol so that's why I'm affirming believe we're in getting a physical also perceptual vision hearing make sure all your fat you know everything's in a good place that's a wrap on the first part of our conversation as I noted at the top it would be much appreciated if you spread the word to anyone else who you think might enjoy the show until next time