14 May 2023
During Mental Health Awareness Week the College is raising awareness of the challenges people with serious mental illnesses, or SMIs, face,
Rehabilitation psychiatry plays a crucial role in helping individuals with serious mental illnesses to achieve their full potential and lead fulfilling lives.
In this podcast we hear from Dr Katie Fergus, an expert in rehabilitation psychiatry with a wealth of experience in this field
Liam Vernon: Welcome to the Royal College of Psychiatrists podcast. I’m Liam, a Social Media Officer & Digital Producer at the college and I'm excited to introduce this fantastic episode, which we recorded to coincide with Mental Health Awareness Week.
During Mental Health Awareness Week the College is raising awareness of the challenges people with serious mental illnesses, or SMIs, face, and in this discussion we're talking to a rehabilitation psychiatrist.
As mental health awareness continues to grow, rehabilitation psychiatry plays a crucial role in helping individuals with serious mental illnesses to achieve their full potential and lead fulfilling lives.
I'm delighted to be joined by Dr Katie Fergus, an expert in rehabilitation psychiatry with a wealth of experience in this field. So without further ado - let us begin.
Hi Katie, and welcome to the podcast! Can you just introduce yourself and tell us a little bit about you and the setting you work in?
Dr Katie Fergus: Yeah. Thanks, Liam. So I'm Dr Katie Fergus. I work as a consultant rehabilitation psychiatrist in Cardiff and Vale University Health Board in Wales. As a rehabilitation psychiatrist, I work with people with some of the most severe and enduring conditions that we encounter in psychiatry, primarily people with complex psychosis, so this tends to be people who've developed a psychotic illness and that their symptoms just haven't responded to what we think of as conventional treatment.
They continue to experience symptoms such as hallucinations, so classically hearing voices which tend to be quite negative or derogatory or giving commands, delusions, so fixed false beliefs that are, you know, usually described as being paranoid or idea being persecuted, you know being being followed, being under surveillance, people meaning them harm, disorganised thinking, beliefs about their thoughts being interfered with or, you know, broadcast to others. And you know, these can be really distressing symptoms and directly influence someone's decision making processes and significantly interfere with a person's ability to complete just you know, normal normal daily activities. You know, just imagine how hard it must be to to get on a bus or walk around a supermarket or a Town Centre if you're convinced that you're at extreme risk from everybody around you or you know how hard it is to concentrate on holding a conversation when you've got another voice or voices that you can can hear at the same time.
I remember doing a teaching session when I was a trainee in which we were asked to concentrate on someone reading a passage from a book while somebody else stood kind of just behind us and talked in our ear, and you know where we were asked questions about the passage from the book. No one could. No one could answer any of the questions because we've been so distracted, you know, that's what life is like for some people with those kinds of hallucinations, you know, it's hard.
Then I guess in addition to those symptoms, which are what people, I guess classically think of as psychosis, we also see what's called the negative syndrome. So this is a collection of symptoms, including things like lack of energy, lack of motivation, difficulty initiating actions, lack of emotion and and those problems. They're often the harder things to deal with. You know, they can make doing what most people think of as the simplest of tasks, like having a shower or getting dressed or making food for yourself or something that can make it just feel impossibly hard.
And these combinations of challenges can just result in enormous levels of disability.
And you know, typically these conditions usually first hit people when they're still quite early in their adult life. You know, it's often late adolescence or the early early 20s. You know sometimes before many of the life skills that lots of us take for granted, you're cooking, managing our money, managing our emotions, maintaining friendships and relationships. You know, they haven't been learned yet or developed. So, you know, people are starting from a very tricky point.
Um, the evidence suggests that somewhere between sort of a quarter or 1/3 of people who experience a psychotic episode never have another one, and are able just to get back on with their lives. It's thought then that probably around and yeah, there's various numbers quoted out there, but they're generally around about another 25% go on to have further episodes of psychosis but maintain a reasonable level of functioning or or perhaps just require a little bit of ongoing support.
But we know that around 15% of 50 to to perhaps 25% of those who experience psychosis find that their symptoms just never go away, despite the standard battery of medications, psychological therapies, social interventions and these, these individuals often have, you know, multiple or lengthy admissions to hospital, sometimes for at least part of it under the Mental Health Act, they lose touch with their networks, their hobbies, their lives outside of a hospital environment and and become isolated and I guess what's often referred to as institutionalised.
Alternatively these people live extremely difficult lives in the community, isolated from their friends and family, retreating from their usual activities and not leaving the house, not coming to the attention of health or social care, but living a very impoverished existence for a very long time.
Lots of them will experience additional psychiatric conditions alongside the psychosis as well as a whole range of problems with their physical health, which they struggle to get proper support with. These are the people that rehabilitation psychiatry services are for.
You know, what we're talking about here is a condition that isn't that common, you know, schizophrenia is specifically thought to affect fewer than one in 100 people in their lifetime. So then saying that of that very small population we as a specialist service are only going to look at around 15 to 20% of them you can see it's sort of a very low volume but very high need Group. One might question the need for an entire specialist service to be dedicated to such a small group of people, and sadly, I think that exact logic has been applied at times when finances are tight and and demands are, you know, elsewhere and services are stretched and has ultimately led to the the loss of a lot of these services with I think really catastrophic results for people with complex psychosis. Um so severe and enduring schizophrenia or or complex psychosis, as it's now often referred to as one of the leading causes of disability and burden of disease in the world. Despite affecting such a small number of people. That that should in itself tell you something about the severity of the condition at its worst, and the value to society as well as to the individual of providing effective rehabilitative care.
Increasingly rehabilitation services are actually shifting towards being known as rehabilitation and recovery services, and that's certainly how we kind of badge ourselves here in Cardiff.
Um, I think many people are familiar with the concept of rehabilitation. You know, being a sort of a set of measures aimed at reducing levels of disability through kind of relearning or adapting skills that have been lost, and enabling people to get back involved in society. The concept of recovery is perhaps slightly less well understood.
This aims to support an individual to live well with their symptoms, you know, minimising them as as minimising the symptoms as far as is possible but not putting an emphasis on a on a mission to completely eradicate the symptoms, you know, we're not looking for for cure. You know we’re teaching people effective ways to manage the experience of perhaps hearing voices or to challenge some of their unusual thoughts or work around their perhaps disorganised patterns of thinking so that the symptoms have less of an impact on their life.
Crucially, within the recovery focus within the recovery approach, the focus is on enabling each individual to step and work towards goals that are meaningful to them and that enable them to live a life that's personally fulfilling and enjoyable. You know, accepting that often this may look very different to the life that they envisaged for themselves before the start of their illness. You know often people who experience psychosis assume that they will then immediately and automatically not be capable of things like college, university, work, relationships, marriage, parenting, and sadly, society and to some extent, healthcare professionals tend to reinforce that message.
You know, we worry about people getting stressed or experiencing failure. So we say you shouldn't do that. You know it might be too, it might be too difficult. We don't want you becoming unwell. You know very, very well meaning perhaps, but ultimately depriving the individual of the kind of everyday things that all adults should have the option of striving for.
And you can see then I guess why so many people develop a sense of hopelessness and helplessness after the onset of psychosis. Recovery services aim to break down those myths to instil hope in individuals and their families and support networks, and to enable people to achieve the goals that they choose for themselves based on their own, their own desires, their own priorities. So it's kind of a recovery of the life that we're talking about, not necessarily recovery from illness which might be what we've first think of when we think about the word recovery in the context of health.
My role as a rehabilitation psychiatrist is to manage the medical components of that recovery and to lead the multidisciplinary team to work collaboratively with each individual patient and their families or support networks to really try and empower them to take back control of their life and make it what they want it to be.
LV: So why did you choose rehabilitation psychiatry and what do you find most rewarding about it?
KF: I kind of realised quite early on in my medical career that the part of the job of a doctor that I really enjoyed was getting to know the patients really well and trying to understand how their illnesses affect their lives.
You know a huge part of your task as the doctor is to assess, examine, arrive at a diagnosis, identify the best treatment and I found it too difficult to ignore the person underneath all that stuff. You know that sense that it isn't just something that's happening to a body or a set of organs, it's happening to a whole person who has roles and hopes and dreams. That may well be profoundly altered by the outcome of your poking, prodding, labelling, treating.
You know, it's part of what drew me to psychiatry as a specialty in the first place. Sadly the workload pressures on doctors these days make it really difficult to spend the kind of time that you might like to with your patients, and there's a real danger of the conveyor belt approach becoming the only way to get through the sheer volume of work. I distinctly remember getting told off in one of my foundation year jobs in one of the surgical specialties for wasting time talking to the patients instead of getting my long list of jobs done. And that never really sat well with me. So I guess in psychiatry I found a world in which in order to be effective, you have to dig that little bit deeper into the lives of the people that you work with to develop that deeper understanding of their past and their present.
But even within this specialty, the demands on the service are such that it can be difficult to see patients as often or for as long as you ideally would. I look at the work that my my general adult colleagues do in the Community, mental health teams and on the acute treatment wards, the the amount that they have to get through, I mean all of the number of patients that they're managing on their caseloads, the the enormity of the decisions that they're making day in day out based on, you know, sometimes perhaps less information than and they might want in an ideal world, I guess it comes down to whether you can be satisfied that you have the information that you need versus perhaps striving for as much information as you can have. You know, and I'm much more comfortable with the latter of those two situations.
You know, I really don't think I could do acute work again. You know, I like detail and data and I guess I've always been something of a kind of a long game type.
Umm, so I was lucky enough during my training during my registrar years to get a chance to do a post in rehabilitation psychiatry and I very quickly realised that it was the place for me. You know, it really satisfied my need to thoroughly explore people's lives with them, to help them to understand their experiences, and to think about what their future could be like if they dared themselves to imagine and believe in it. It offers me the opportunity to work really intensively with people for a prolonged period of time to get to know about the best and the worst of their experiences and to understand and appreciate their values. You know their hopes, their dreams, many of which had been unnecessarily abandoned following the development of their illness.
Umm, so by the time people get to a rehabilitation and recovery service, they've been unwell for a really long time. You know, sometimes, sometimes they’ll spend many, many years in the hospital. You have people coming to me. You're having spent over a decade in hospital and they've they've sometimes had given up on life ever being any different, and often others have given up on them, too. You know, families, friends, sometimes even healthcare professionals.
Umm, I guess I've always been drawn to the underdog to some extent, but for me there's something about working with the most disadvantaged of the disadvantaged, the most vulnerable, the most in need, there's something about that that really appeals to me. So to have the opportunity to work alongside people like this day in, day out, and show them a different future is possible is a real privilege and my role is often to hold hope for these people until they rediscover some of that hope for themselves.
Don't get me wrong, it's hard work. I think unpicking the worst things that have happened to people, seeing them enduring symptoms, that that can often be described as tormenting or at times even torturing them. Yeah, it requires a certain level of resilience and and scaling, managing one's own emotions.
And the work takes time. You know, it's often years of working with someone in order to see your mutual hard work coming to fruition, but when it does, you know when you see someone getting back to college, starting voluntary work or paid employment, reconnecting with family or friends, or picking up old hobbies or you know, even just remaining at home rather than being in hospital and and seeing them happy, redeveloping a sense of identity and self worth that they've been robbed of by their psychosis. It's a really powerful thing and deeply satisfying and rewarding to have been a part of.
You know, I think the job teaches you to really appreciate and celebrate the small wins as well as the big step forwards. You can really help you to gain a perspective on what's important in life.
LV: Can you speak to the importance of repairing relationships and reestablishing social skills during the rehabilitation process?
KF: Yeah, I mean one of the one of the many cruelties of severe and enduring mental health conditions is the toll they can take on relationships, you know, particularly in complex psychosis.
Family members and friends can become exhausted by the demands of supporting someone with this type of illness. And, sadly, but perhaps understandably, you often drift away. Umm, I think on top of that, family members in particular are often caught up in people's delusions and may well be viewed with suspicion or anger by the individual experiencing the psychosis. Some family members may well experience aggression as a result of this and further alienates the individual from their loved ones and support network.
Um like, contrary to popular belief, people with schizophrenia or complex psychotic conditions are not usually violent or dangerous, despite how they are often portrayed. I mean, and indeed, they're more likely to be the victim of a violent crime than the perpetrator, but I guess it would be disingenuous to claim that violence never happens. And it's a difficult truth that much of this aggression, when it does happen, is directed towards family members and that can be really difficult to come back from, you know, for both the family members.
And for the individual themselves, when they, you know, reach a point in their recovery where they realise how they've how they've treated their loved ones, you know that can bring with it new barriers, you know, through guilt or shame or embarrassment. And and there's a huge amount to work on there.
You know, I'm often really struck by how many of the patients I work with spend years on my wards without ever being visited by a family member, you know, by how many times you try to explore who they might like to have involved in their care, only to to hear them say that there isn't anyone. The depth of the isolation can be heartbreaking at times.
Similarly, I guess seeing family members coming to the ward, attending Ward rounds and meetings and desperately trying to understand what is happening to their loved one, you know, trying to make sense of this bizarre set of circumstances or beliefs that surround someone that they're… They look so different to the person they knew. I mean, that could be a really difficult thing to witness.
On the flip side, I guess seeing someone reconnecting with friends and family as a really joyous thing and and something that's actively and and you know creatively encouraged during people's time working with us, making a really rewarding area to see progress in watching people come back together and growing in their their shared understanding of their their illness and experiences.
I'm currently training in the open dialogue approach, which is a particular approach to care and treatment that has has yielded really, really good results for people with psychosis in Finland and increasingly across other parts of the world. This looks really specifically at working with individuals within their support networks and is something that I'm really excited about using more in my own place of work.
Yeah, the, the, the nature of the illnesses that I tend to deal with um, you know, with, with paranoia and ideas of persecution often being quite prominent features the high incidence of adverse life events. You know, often people have histories of various forms of abuse in both childhood and adulthood. And you know, the experience of stigmatising and prejudicial attitudes by society can make it really, really hard for people with severe and enduring psychotic conditions to trust people and form relationships, but in general, as humans we’re social creatures, you know, we're not designed to live and isolated existence and loneliness can be a huge problem for the people that I work with.
The work that we do to enable people just to feel comfortable in the presence of others, to to relearn how to and initiate, develop, and maintain relationships. You know whether those are friendships, relationships with family or romantic relationships. It's a crucial part of most people's recovery.
And I guess you know, I, I I frequently thoroughly enjoy conversing with my patients, you know, not not about anything clinical, but about everyday things. You have some of my best conversations with my patients. So when we're not talking about their illness or their life or anything and we're just talking about current affairs, sports, movies, music, run-of-the-mill conversations that I might have with my colleagues, friends, family, you know, normal everyday stuff and I I think that people sometimes forget that people with psychosis are still very capable of engaging in really good conversation if if only you take the you take the time to find the right topic. And I think that's where we're getting to know them comes in finding out their likes, their strengths of which they're usually many more than people think and encouraging them to make use of those strengths can be really empowering.
We've had people on the ward who are really talented musicians who have entertained the wards with their songs and musics and got singalongs going, we’ve had artists who taught other people how to draw. People putting together quizzes or using their areas of interest. We had a DJ once who brought decks in and just got everybody up dancing. You know the value of this social activity and the connectivity with staff and peers that results from that kind of stuff is immeasurable. And I've seen some fabulous examples of kind of mutually supportive friendships developing within the wards, you know that peer-to-peer support can be so powerful in inspiring both parties to take steps forward in their journey through a rehabilitation program, you know, sometimes they can probably do more for each other than we can do for them, you know, and that that resource of the expert by lived experience is something that needs to be respected and nurtured by services.
You know, I view peer support workers, peer mentors as essential members of a recovery focused, multidisciplinary team. And you know, I'd really love to see more attention paid to that resource and see it supported, invested, and invested in properly because you know this, the social reconnection, that that can stem from is, you know, at the heart of the ability to be properly socially included.
LV: So moving on now from patients to the wider public - do you think people know enough about people with schizophrenia, and understand enough about psychosis?
KF: Sadly no, no, I think it's a horribly misunderstood condition that that has, you know so much myth associated with it that it's really difficult to kind of dispel the the negative connotations that pop up when when the words psychosis or schizophrenia are mentioned, you know, I think even within healthcare settings, psychosis is very poorly understood and people with enduring complex psychotic disorders fall victim to assumptions and prejudice and suffer as a result. And I mean that's within healthcare professionals.
You know, when I was at medical school, we were taught that people with schizophrenia lived on average,10 years fewer than the average life expectancy. In the past 20 years or so, that gap has widened further, you know, with 20 years less than average now being the often quoted statistic.
You know I can't think of many, if any conditions in which the prognosis in terms of life expectancy is worsened and yet you never, you never hear of it outside of psychiatric circles, you know, where's the moral outrage about it? You know, my suspicion is that if this was any other condition, there would be uproar and, you know, calls for reviews and policy change and investment but I think the misunderstanding of psychosis probably makes people really reticent to delve too deeply into the problem. You know, we know that the majority of the excess deaths in the population with complex psychosis occur from what's referred to as natural illness, you know, heart attacks, for example.
People with chronic psychosis and you find it really hard to navigate the healthcare system and you know, such as they miss out on many of the strategies and interventions that are widely available to to maintain population health levels of take up for screening programs, for example, very low within this population, your attendance within primary care settings for chronic disease monitoring, diabetes, asthma, making sure that they're well managed is poor, you know, responding to letters from hospital travelling to outpatient clinics, tolerating a busy waiting room, communicating with the doctor can can all be overwhelming barriers to people getting their their health problems addressed. Even just recognising acute physical health problems can be troublesome for them. And then navigating the system to book a GP appointment can be near impossible.
I guess I've got on to this because, you know, disappointingly, I have more examples than I care to mention of situations in which my patients have been, I've felt, actively discriminated against by clinicians in other specialties being offered less than gold standard care for no other reason than people being worried about someone with psychosis being being on one of their wards or in their clinic.
You know, there is still that level of fear, or I don't know what it is, but there is still a lot of work to be done to make sure that this doesn't continue and I guess it's a key message that I try to instil in the medical student, you know, the doctors of tomorrow when they're on psychiatric placements that, you know, these are people who have the same needs as the rest of the population and no reason to not have the same access.
I guess that also goes for for thinking about all of the other agencies that are are patients you know might have reason to have contact with the social services, housing, DWP, police, probation, employers, these people could all play a vital role in supporting someone's recovery and having an awareness of and a sensitivity to the particular needs of people who experience psychosis could make a huge difference in that person's experience of those.
Services and and result in better outcomes for all.
Think more than about the general public, which I think is what you actually asked about. I suspect the understanding of psychosis is pretty low, but that's not perhaps surprising given that it's very rarely talked about. Mental health has been a hot topic for some time now with numerous celebrities or sports people. Other high profile individuals talking about mental health, perhaps talk about their own mental health problems and advocating for greater awareness about suicide, depression, bipolar disorder, OCD, autism and this is great, you know, it's it's a good thing breaking down the stigma that surrounds mental health problems and has surrounding them for too long.
And ensuring that people feel able to, to speak up about this, the symptoms and and to have places where they can go to support you. It's a really welcome development and one that I absolutely wholeheartedly obviously support to prevent countless people suffering unnecessarily.
But psychosis is noticeably absent from these discussions and and still seems to be something of a taboo subject, and I think you know, sadly one of the the inadvertent consequences of a giant spotlight being shone on some parts of mental illness and mental health and wellbeing, and these are tended to be the kind of conditions that we can all relate to depression, anxiety. That spotlight being shone on them has kind of served to shove complex psychosis, kind of even further back into the the deepest, darkest corner here at back end into the depth you know a quick search through mental health related podcasts or articles you know rebuild hundreds, thousands of of things on depression and anxiety, autism.
And I don't mean to diminish the importance and relevance of discussing those conditions because they cause a lot of suffering for a lot of people. But where's psychosis? Where is the discussion, the analysis or the exploration of you know one of the most disabling conditions in Western society and and and globally, and until people start talking about it and learning about it, the myths that have been perpetuated since the condition was first described, will continue to Make individuals feel sort of ostracised.
People who experience symptoms of psychosis and impair their ability and willingness to to seek help. I think that as a society, we need to see change. Imagine how hard it is to work so hard to overcome so many challenges to social inclusion, only to discover that the very society that you're trying to include yourself in doesn't want you fears you, mocks you, sees you as less than somehow, and that's sadly is the experience of too many of the people that I work with.
You know, I think that as a society, if we wish to judge ourselves by how we treat our most vulnerable, our most in need members, then we could do a lot worse than to look at our collective attitude towards people with psychosis. You know, to show them a little more kindness, a little more compassion, to not rush to judgments or assumptions about their intellectual capabilities, or their moral character, or the risk that you think that they might pose but instead I guess to see them as a person, you are a person who has an illness just like you or I could get. You know a person who, despite their illness and the significant challenges it can bring, can still offer a lot to society you know, could live a meaningful, peaceful, contributing life. You know, if we just made a few adjustments and gave them a chance.
LV: As someone working on the frontline is there anything else that can be done to draw attention to it? A campaign? More conversations? What do you think?
KF: I would, I would really love for that to be more conversation about complex psychosis, about schizophrenia. You know, whatever. Whatever you want to call it, we need more conversation about it. We need that spotlight to shift to that population for a while, you know?
It's a subject that that very rarely comes up in, in sort of political situations, it doesn't tend to feature very highly in policy. You know strategic work that goes on within government certainly, you know, I've previously worked as the lead for policy and public affairs for the Royal College of Psychiatrists in Wales, and I was actively involved in discussions with Welsh Government in in a range of forums and you know in the three or four years that I did that role, I I'm not sure that I heard them talk about psychosis once in all the meetings that I went to.
Umm, so I think definitely some PR work, you know, something to shift the narrative away from the negative um to to get people recognising it as an illness like any other, and to to recognise that this does not spell the end for people, and that there is hope, and that these people have value and that they can contribute to to society. You know, I think working with employers, people who can offer opportunities to, to people with mental health problems and then psychosis in particular.
You know that could be transformative for some people. That opportunity to have the support, to return to structured meaningful activity, that gives you a place, it gives you some to get out of bed for a place to go, something to hang your week around. You know that's so valuable to all of us. It grounds us so much of our sense of identity, self-esteem, self-worth is wrapped up in those kinds of roles.
And yeah, the absence of that from someone's life can be really destructive. You know, these are the things that give us meaning and purpose and the opportunity to experience a sense of mastery and and and pleasure. You know, all of which have protective factors for good mental health.
Umm, you know, I look at the work that, you know, some employers like Timpsons have done with a population who have historically been seen as difficult to employ. And I guess I tried to hold on to some hope that one day a combination of policy work, government or political will, and perhaps big employers might just get behind offering something similar for people with complex psychosis.
Because it, you know, it has so much to offer, but that kind of change is only gonna come from awareness, from conversation, from education, about the condition and from starting to do the difficult work of breaking down the myths and stigma that have been allowed to develop.
LV: Yeah, so following on from that, has the portrayal of schizophrenia in the media had a really negative impact on the way it is perceived and treated? I’m thinking of films like The Joker, on TV, what do you think?
KF: Yeah, I mean, sadly the media is where most people are going to get there, information about psychosis and and sadly, as you say, portrayals of mental illness in general, but psychosis in particular have historically been quite unhelpful. You know, I think this is something that has changed more recently. And I think more sensitivity is starting to be shown towards how mental health problems are presented.
But we're still a long way off translating to a genuine shift in attitude or acceptance, particularly when it comes to conditions like psychosis and schizophrenia. You know the myths of dangerousness perpetuated by sensationalist reporting in the news or a need for drama on TV or at the cinema. They persist, and they continue to present a barrier to people with psychosis seeking help and achieving inclusion.
And it isn't even just portrayals of psychosis itself. You know, I'm regularly dismayed by the language that's used in the media to describe any kind of unwanted or unusual behaviour as psychotic. You know, you see someone becoming angry or aggressive or smashing something up in a film or on TV. And it's highly likely that another character will subsequently refer to them as going psychotic. And this kind of misuse of language, the misuse of a specific medical term can do untold harm, as can the tendency to blame people for the development of these kinds of conditions.
Umm, you know, I think we search for meaning or explanation when people do terrible things that we don't understand. And I think I think as a you know as humans I think it's easier for us to to collectively make the assumption that when people behave in a way that we don't like or we don't understand that we just we jump to the conclusion that they must have a mental health problem because that I don't know maybe it makes us feel safer makes us feel less threatened in our own identities rather than an accepting that that some people just do bad things, I think I think the the psychosis or schizophrenia or even just a very generic mental health label serves a purpose for us rather than for the individual.
I guess even if they're not being thought of as dangerous people, you know, people with psychosis are portrayed as sort of incompetent or helpless, with no prospects, which is a world away from the truth.
We've seen real progress in the achievements of people with physical disabilities who are respected and celebrated when once they were looked on as people who need looking after.
Now, I guess I can only hope that at some point the same will happen for those whose disabilities arrive from mental rather than physical health causes.
LV: Well Katie, thank you for joining me today. It's been a really insightful conversation and a pleasure to speak with you. So thank you so much.
KF: Thanks very much Liam.