Transcription
So, I'm going to turn it over to Dr. Montero, and then her and I are both going to work through these slides with you as we have some lively discussion. So, thank you, Dr. Montero.
Thank you, Dr. Lambert. I'm Ann Mary Montto, and I am deeply honored to be here with you all today. I brought up my phone just so I can try to stay on track for timing because I am so passionate about these topics and I feel there is so much to discuss. I've been honored to work with some of you directly. I've been deeply honored to be, uh, included in the past with AIHA, and I just want to ask for a moment if we could just give Dr. Lambert and Megan and their team a round of applause. Isn't this phenomenal? Isn't this amazing? And to be able to capture live data with feedback from you in the moment while we're discussing this, this is like a social scientist's dream. So, I am thrilled. I'm thrilled.
Although I am, I want to start off on a note of compassion. What we're here to talk about today is extremely important and extremely, uh, challenging. Living with an autoimmune condition predisposes people to a number of challenges. I do not have to tell anybody in this room how hard the physical challenges can be. Pervasive fatigue, intensive fatigue, the the kind that friends don't understand, that might say, "Take a nap. You'll feel better later." Or, "Hope you, hope you get some rest." They have no idea the intensity and the duration. And then what kind of toll that takes on your mental health, having something that others can't see, what we call an invisible illness, from the outside is not evident how you're feeling necessarily on the inside. Some people like to put themselves together well, that may not match how they're feeling internally, right? Days that your pain or your fa fatigue may be off the charts, and you may still make an effort to pick up your kids and carpool or go do something, and that may be all you do for two or three days. But to other people, they may see you and think, "Oh, you look great." Thinking everything's fine, right?
And then there's what we call dissonance. There's like an internal, um, kind of a non-match between what you're feeling, excuse me, on some level, either what you're doing or what's happening around you. And that can create some emotional challenges. We know emotional challenges are rampant. Just the physical symptoms alone are enough to create that, aren't they? Just common sense. Anyone who's experiencing fatigue, pain, those can create social isolation. When you don't, uh, engage as much with others, pardon me, naturally, that that will cause some dip in mood. It can cause anxiety about what others think about you're not participating in activities. We're already having a national conversation about what's being called the loneliness pandemic, the loneliness epidemic, excuse me. And with that, we are at increased risk when we have other physical and mental health symptoms going on.
This is the only slide where I, I put, uh, research. I know people aren't here to hear all kinds of research, but you probably know, um, both from other talks today, from your own research, and from the great information on the AIHA website, that depression and anxiety are unfortunately occurring four to five times that of the general population. People with autoimmune conditions in general have much higher rates of having depression and anxiety. So, this is something we want to be mindful of and on the lookout for and proactive to treat. And I just want to follow up with our last speaker who commented on CBT being, um, efficacious to some degree. We know cognitive behavioral therapy has, it's our gold standard for treatment and can help. So, depression and anxiety with CBT and other treatments, it's very treatable. We can help you at a minimum feel heard, seen, and supported. And you may be able to shift, I call it turning the dial down on some of the emotional distress and even sometimes the physical symptoms.
There is a study on, uh, mindfulness-based stress reduction. For example, mindfulness is millennia old, but, uh, someone named Dr. John Kabidzen has kind of pioneered modern inclusion of that in our national discussion for what we can do to treat, uh, symptoms. And I know we need to get to our questions, but mindfulness-based stress reduction is just one example of psychotherapy has helped reduce not only depression and anxiety, but cytokine inflammation in the body. So, we know that there are lasting changes not only that can occur in treatment but lasting even 12 months after treatment in that study in particular. So, working with the mind can have profound effects on the body.
But let me ask you about your experience. So, if we get to, uh, Dr. Lambert's going to assist me here with these questions. We want to understand better directly that we have you here. You are the experts on your bodies, on your conditions, whether you're patient or caregiver, just someone interested to attend the conference. We are so thrilled you're here. We appreciate hearing from you. Uh, recalling, I'm sure Dr. Lam has explained this data is aggregated and anonymous. Correct?
So, no one will know.
No one will know directly what you said.
So, anything that you say will not, will not be able to be traced to you. But we appreciate understanding. What is your sense of how well you feel you understand the condition itself?
And I do want to make sure that we have caregivers and others in the audience. If we could direct this just at patients for this one, and we'll probably take about a minute per question just because we have a number of them we'd like to get through.
So, the responses thus far, Dr. Montto, about 58% agree. Uh, the other outlier is strongly agree, which is good at 22%, but still, we have about 25% that say disagree or neutral. No strongly disagrees.
Okay. So, there's room to grow there. Sounds like there many feel they have a good handle, could be a touch better, and a number of people feel they don't know enough, nearly enough at all. So, absolutely an opportunity for us to partner with you in education, both with the AIHA web resources and directly with healthcare providers. All right. If you were to outline the greatest challenge to coping, and we try to identify a range of options here, would you anchor that with your own understanding, your the first, well, the first question was about how well you feel you understand the condition itself, how well you feel people around you understand it and support you, or to the degree to which there might be stigma, challenges around you in terms of your healthcare team, and particularly communication with your healthcare team, if that's a barrier to care. We hope not. Physical symptoms. We've mentioned the profound effect of pain, fatigue, sleep disruption. And then lastly, psychological challenges, anxiety, depression, and even hopelessness.
So, just to summarize what we have thus far. So, uh, the physical symptoms are quite substantial at 47% of the response rate. 27% are the emotional challenges. So, those are the core pieces and very consistent with what I see in the clinic as well. The next one is limited social support and stigma, and that's at 13%. Reassuringly, the medical provider communication is down below 10%. So, that's a big win. I'd like to hear that.
We're relieved to hear that. But we always stand ready to hear more and grow. So, thank you for the feedback. That's very consistent with the data we understand from the literature too, that physical symptoms are in the lead of creating terrible challenges in people's quality of life, with mental and emotional symptoms right behind it. So, thank you, Dr. Lambert.
If we turn next to focus on the issue of stigma. We know from the World Health Organization that many people, even some studies say up to 70% of people who recognize they have mental health needs don't reach out to get treatment. And a big reason for that is stigma. A lot of people still feel shy about sharing that they have symptoms at all, and especially symptoms as personal as mental health challenges, even though I would normalize that as a part of our humanity and a very understandable part of our humanity, especially when you have ongoing medical distress. So, with that, can you share how comfortable you are sharing openly with others about autoimmune hepatitis diagnosis?
So, from the responses thus far, uh, so reassuringly agree and strongly agree, that totals is about 70%, which is great news. Disagree is about 20%, neutral 7%, and reassuringly, strongly disagree at 5%.
Wow. Sounds like most people are fairly open. I'm glad to hear it. Sounds like the barriers are lower than they might be for some. So, when we do share, do you expect that others may not, or I shouldn't say when we do share, reasons for your sharing or not sharing, do you anticipate that others will not fully understand or accept your diagnosis of autoimmune hepatitis if you were to communicate that you had it? How do you, how understanding do you feel they would be?
So, in terms of responses thus far, so agree is the the majority at 55%, strongly agree is 29%, which is great. Neutral and below totals about maybe 20% or so.
So, it sounds like, and this was phrased, I'm sorry if I said this in a misleading way. This statement says, "I feel that others do not fully understand or accept my diagnosis." And Dr. Lambert, the majority, he's saying either agree or strongly agree. That sounds like high, high challenges to feeling understood.
If we go to the next slide. Yep.
Um, we want to ask about the expected impact of having autoimmune hepatitis on your functioning. It reads, "I have faced challenges at work or school because of others' beliefs about my health diagnosis." Has this prevented you from doing anything?
And based on responses, uh, it's false in about 62%, whereas true in about 38%.
Wow. So, almost, uh, four in 10 feel it has unfortunately impacted, uh, their ability to engage in things they wish because of others' uh, beliefs, maybe false beliefs. Unfortunately, that's where stigma is rooted, isn't it? When it comes to telling others about my autoimmune diagnosis, we wanted to ask about the degree to which you might disclose. So, do you share openly with almost everyone? Are you an open book? Do you share only with people you trust, like close friends or family? Do you tell only your doctor, your medical team, hopefully people that you trust or know are there to care for you? Do you share only on a need-to-know basis? And you might avoid particularly naming autoimmune hepatitis as the condition. Kind of be guarded in your disclosure, or very guarded. Do you rarely or never disclose any information about your condition?
So, the leading on here is tell only close friends or family at 44%, where sharing openly with almost everyone's about 36%. The need-to-know is about 20%, and rarely is only 3%. So, it sounds like things are skewed more positively toward open disclosure.
Yeah.
Do you mind if I set this here? Thank you.
Okay. And the reasons for not sharing. We just want to explore the anticipated responses from others very briefly. How do you expect others would respond? This often has to do with the expectation of why to disclose or not disclose. Do you expect they would provide unconditional loving support, or provide support but only to a certain degree, not respond much at all, judge you or your condition unfairly, back to the stigma expectation, or even expect actual negative consequences from any disclosure? I might risk my job or my friendships or my being invited out regularly if people know.
So, based on the responses thus far, it seems to be a close between two, three, and four. That would be provide supportive on certain levels, not respond much, and judge me unfairly. So, it's about a third each.
Okay. So, that, that is more consistent with what I hear in clinic, that there's some skepticism about how other people may respond. And this is, uh, an ongoing experience, right? Trying to help educate people to the degree that you're comfortable. But, uh, some, some are more open than others. I understand. Okay.
I'd like to pivot toward mental health. We've established, and the literature, that patients who experience autoimmune conditions are at increased risk of mental health challenges. And mental health challenges, we know, predispose us further to autoimmune difficulty. And so, it can become a reciprocal, uh, pathway. We want to understand directly with you what your experience is like. So, in an anonymous way, if you're comfortable letting us know, can you tell us how many of you within the last month or so have felt down, depressed, or hopeless because of your condition or related to your health or concerns about your health?
Oh, sorry. What's next on their slides?
No, they should be open now.
Okay.
So, it looks like most people are finding it. So, the majority is 55% moderate. I get down sometimes. Uh, whereas the other side, it's about 30% low. Oh, I'm sorry. I apologize. I'm, I made the same mistake. So, similar though, sometimes it's about 53%, none ever is 14%, a little is 20%. But there is a quarter, 23% that says a lot/often.
Okay. So, I'm, I'm hearing as I've listened to that with my psychologist ears, that about half of the people were experiencing at least some depression. And this is very consistent with the literature. At least 50% of people endure some symptoms consistent with major depression with autoimmune hepatitis, and more than that with any type of autoimmune condition. So, you are in good company. And I would just gently remind you as we go to the next slide, that anyone who is experiencing more lasting or intensive symptoms, please seek professional support. I will remain available here after our talk today. You can find me on the website. You can find me and a lot of other providers who truly care at IU Health and across the country. So, please don't hesitate to reach out. The stigma is absent on our end.
So, when you have experienced depressive symptoms, feeling blue, feeling loss of hope, sometimes even loss of interest or energy to participate, like you just feel numb, you don't feel anything. When you've experienced those feelings, can you tell us the intensity ranging from I don't even feel that to low, I expect this will pass, medium, high, this is heavy and hard to change, or persisting and lasting. I'm sorry, persisting and intensive.
So, again, 50% is moderate. I get down sometimes, whereas the the other 30% or so is non-existent to low. But importantly, about 15% are split between high and extreme.
Okay, thank you for letting us know. We want to be attentive to that and again, mindful that where, when present, we want to hone in for treatment. When it's present even to some degree, there's an opportunity to be proactive. So, we'll talk about some ways to do that today. Let's shift to anxiety symptoms. I think this is just a common denominator of our humanity. To worry is to be alive. You're concerned about things being okay. This is, uh, if you weren't concerned at times, that would be abnormal. So, um, let's just ask within a similar time frame, within the last month, how many of you have felt concern, um, including about health, that may cause you anxiety?
So, it's low at about 44%, which is reassuring. Moderate, though, is 41%, and then high is 12%.
Okay. And when you have felt that, if we go to the next slide, please, what kind of intensity would you endorse? This may feel redundant, but to us, this is important to know when it's present, how strongly do you feel it?
Give that just a moment. Yeah, I want to make sure I'm on the right one, too. So, in terms of the intensity, 40% moderate, 46% low, but there's still 13% that are high.
Okay. So, I would count 40 and 13 to give me just, just over half are experiencing at least moderate levels of anxiety, and specifically around health. That is again, very consistent with the literature. We understand that this experience predisposes you. I recognize we're asking you at a conference about this. So, this is top of mind for us. It's in focus, but we're asking you in general how much you're feeling this. So, I, I appreciate your sharing. You are in good company and, um, we understand and want to support you in that. Okay.
I'd like to ask next about the, uh, reciprocal interaction. This is a fancy way to say kind of a two-way arrow between our physical and emotional symptoms. Kind of like an arrow from, uh, the liver up to the heart or mind, if you want. It just reads, "My autoimmune symptoms cause my worry or sadness to increase. My health is stressful to me." In other words, does concern about your autoimmune hepatitis or sadness from it make mental health symptoms worse?
So, the source of stress.
60, about 70% say agree or strongly agree, whereas only 7% say strongly disagree.
So, that is, uh, very humanly understandable. Most of my patients see me because of this very reason, that their health is causing, it's their number one stressor by far. Now, let's look at the converse of that. If we flip that on its head, the, once we understand that certainly health symptoms can cause stress and worry, we also know from how we are biologically wired, this is a normal reaction, that once you have stress and anxiety or depression, that can exacerbate, that means make worse, your physical health challenges, can contribute to sleep disruption, further fatigue, low motivation, and physical reactivity to stress. You can be keyed up and tense.
And so, 50% would agree with that, where 10% strongly agree, everyone else is neutral or below. Okay. Sounds like then we've got a kind of a spread, but again, a good majority endorsing they, they are aware of that physical reactivity to stress, that the likelihood that when you have symptoms, they can make your emotional distress worse, which can in turn make physical distress worse, and we have a cycle. We want to ask specifically which symptoms affect mostly both your mental health and daily functioning, which get in the way the most. Fatigue, low energy, sleep interference, specifically pain, mental health symptoms, including fear of disease progression, anxiety about the future of your condition, or social interference.
So, not surprisingly, fatigue is about 50%, sleep problems is 25%, whereas anxiety, depression, and fear of disease progression is about 20%.
Wow. That is, I'd highlight that with a huge marker. So, that sounds like, if I heard you right, about 70, 75% were in the fatigue or sleep category. So, sleep disruption and fatigue are by far the greatest variables.
Correct.
Okay. That gives us a place to target.
Okay. So, I'm going to bear that in mind as we have our discussion later on. So, just for absence of time, uh, there's only a few questions left on this AIH patient tool. If it'd be okay if you guys would complete those, and we maybe don't talk about them, but we have a session that's directed at caregivers too. And so, we maybe over the next three to four minutes, if we can fly through the caregivers section. Not to be, you know, absent-minded and thinking caregivers aren't important, but I do want to make sure that we focused on the patient.
Understandably. Let's.
So, if you would just finish the AI patient survey, and then we'll transition to the caregiver one.
I think there's only another question or two.
So, for the caregivers in the room, if you can share with us please, how well do you feel you understand autoimmune hepatitis? Like the first question we asked patients.
So, a little bit of a slow uptick here. Is everybody able to get on the other question bank under the live polls?
Can they go back and forth between the questions?
So, you can go back to finish the patient questions later.
So, what we have collected thus far, out of six responses, which is really reassuring, and probably the reason you're here, 100% agree. Actually, one one disagrees and one is neutral.
Okay. Sounds like by and large, there is good understanding. And I would add, the people who are at these conferences are probably an excellent subset of people who would likely be most, um, have the greatest chance for that. Okay. How confident do you feel in your ability to provide emotional and practical support for someone with AIH?
So, the response is agree at 60%, strongly agree 25%, and neutral 17%.
Wow. The overwhelming majority are in good stead in their confident caregiving. Excellent. If we look at barriers for providing support, we first put limited understanding, which sounds like that's that's low. Balancing caregiving with other responsibilities, emotional stress or burnout, limited access to medical care or peer support, or challenges communicating with the healthcare team. Which of these might apply for caregiving barriers?
I don't, sorry, one sec. So, it looks like this is mostly balancing caregiving with work and family responsibilities. That's 63%.
Okay. That makes good sense with what I know as well. The, there can be time and energy demands on multiple fronts. If we look at caregiver emotional well-being, which is critically important, you know that old adage about putting the oxygen mask on yourself first before you assist the person next to you on a hypothetical plane. Uh, this reads, "My role as a caregiver sometimes affects my own mental health. Stress, anxiety, depression, or feeling overwhelmed or exhausted." To what degree do you agree that's true for you?
So, agree is 46%, disagree is 36%.
Okay. So, kind of a balance there. How about how it affects your own physical health? Sleep, energy, nutrition is some examples.
So, it looks like this has already been answered. So, agree is 28%, neutral 28%, and disagree is 24%.
Okay. So, there's again, a good balance there. Some people are still stewarding their own health, others are feeling some deficit. How about this? Uh, particularly affecting your own needs that you might need to set aside in order to provide care for your loved one with AIH, like attending your own doctor's appointments or neglecting exercise or social time.
So, agree is 33%, but disagree is 43%, neutral 20%.
Okay. I'm hearing a really even spread across these. If we try to prioritize which challenge rises to the top as the most interfering factor or the most challenging aspect, would it be physical symptom management with your person you love? Emotional symptom management, medical care management, encouraging compliance with whatever your healthcare team or the patient's healthcare team has recommended, or adjusting to practical realities associated with symptoms, the way it interferes or affects your social life, for example.
So, this also is spread, uh, but number one is 30% for the number one managing physical symptoms, with a close number two at managing emotional symptoms.
Okay. That, that again is consistent with the literature. Those are our top two variables, one right behind the other. Okay. What do you find most helpful? I know we're at the end of our time. Uh, you all can read this on your own. Medications.
Well, this is also on a separate list, I believe. Can you find in your app? This is for both patient and caregivers.
Oh, thank you for prefacing that. Do we have time, Dr. Lamur?
Yep. So, I think we have about one minute to finish, and then we'll, we'll do your next exercise in about six to seven minutes. You probably do this faster without my narrating, but we're trying to identify what are the most helpful resources that you find valuable for coping.
And we're going to just give it another 10 seconds here because everyone's switching over.
And I'm impressed with everyone's fluent navigation of the.
So, the top, the top two seem to be at least at 40% time, patience, and practice. And then 38% is I use all of these. The next one is medications and active medical care.
Excellent. If we go to the next slide, if we were to visualize what what could come in the future that would help you best, would you ask for more caregiver education and training, improved team communications with your healthcare providers, more mental health resources for patients and caregivers alike, more acknowledgement and recognition of caregiver needs, or greater peer support?
And this is a decent split, but the number one is 31% more caregiver education and training. The number two is more mental health resources for both patient and caregivers.
Excellent. Well, I'd like to announce, uh, with Dr. Lambert's permission, we have developed a mental health miniseries that we are going to provide on the website, that we are launching for patients, and I will do a dedicated one for caregivers to be responsive to this data that you shared in real time. So, thank you so much for your, for your interest and feedback today. And maybe if I could just butt in, I, I think that was a really valuable exercise, I think, for you all to see the prevalence of these issues, but also as an organization, as we think about programming the next year ahead. This gives us some real targets to address and, and with collaboration with people like Dr. Montero, this is where we need to be, at least as a nonprofit. So, so thank you.
And we welcome your feedback offline, both for personal needs and any recommendations you have about places that you'd like to see are putting our re resources and research attention. Dr. Lambert, as you know, is a pioneer in the field, and so we're lucky to have his ear today. Uh, I'm happy to hear as well about things you find relevant on the mental health or practical coping front, and about caregivers in particular. I have a passion for caregiver attention. So, what I'd like to offer next, and I'll be mindful of the time, is a brief resource. And I developed one of these already for inclusion on the website, and Dr. Lambert and his team need time to review them. So, I would guess maybe in about a week, these would be available on the website. But I, I do guided imagery exercises as part of relaxation training. My supervisors from Harvard always phrase this really well. We're trying to evoke something in the brain called the relaxation reflex. I love that phrase for a lot of reasons, but in part because it reminds us this is something our brain knows how to do anyway. Our bodies are designed to respond in real time to stress, but also to come down and to help ourselves get into a down place. There's like a 7:1 ratio for how long it takes our bodies to settle back down after getting aroused from stress. So, we try to accelerate that 7:1 ratio with exercises like anxiolytic breathing. I have a module for that on the web page. Anxiolytic breathing is a fancy word for diaphragmatic breathing. Just means trying to help slow your breath, calm your body's response through the vagus nerve. What we're going to do this morning, I'm going to just invite you to participate, if you're comfortable, in a guided imagery exercise that's designed to evoke that very same reflex, help your bodies relax and come down, calm down. We'll have one of these available on the website. But I invite you right now, if you're comfortable, to close your eyes, just get comfortable in the chair. If you could imagine that all of the things that you have on your mind, the paper you've been writing on, the concerns that are within your phone or within the back of your mind from your home or the rest of your life, if you could just imagine, like Disney's Fantasia, that I could just suspend them in time. Just kind of tap the screen behind you and visualize everything just freezing for a moment so that you could be present here with us in this beautiful space, knowing that you are exactly in the right place at the right time.
Let's just take an inb breath, and as you do, imagine breathing in all of the positive intention of our team, from me, from Dr. Lambert, from everyone who's spoken here, and from the people who love you. And visualize that coming in like a column of light. And just following the line of your spine, coming in now, down along the back of your neck, just flooding down past your sternum, around the back of your heart. As you take in another deep breath, imagine that flooding behind your stomach and very gently coming behind your liver. A beautiful liver that's gotten so much attention. And imagine that light just flooding now down to the base of the pelvic girdle and inviting that light to come down the line of each of your legs. And in your mind's eye, make visual contact between your feet and the floor here of our building. And imagine knowing that as your feet make contact, you are safely anchored in this space. Almost like a magnetic resonance could pull you down, anchoring you safely into the earth, past the floor and the foundation, past the dirt and rock and the wet into the center of the earth where everything can be made anew. Let's imagine with that renewal possibility, bringing up energy from the center of the earth that is intended just for you for your own renewal. Let's bring up in your mind's eye, like a line of light from, like reverse force of gravity, that's now coming up with your in loving intention, pulling that past the floorboards and the soles of your feet. I always envision a line of white light, and you can tinge that with your f favorite color. Let's put a little bit of blue or green underneath that and bring that up the length of your legs. And imagine as that line of light passes up your legs, it can help absorb fatigue or achiness. How much your legs have worked to support you this week. So, in thanksgiving for their hard efforts, let's just imagine giving them kind of like a loving wave, an acknowledgement as you pass by, helping absorb any challenges and coming back up now to the pelvic floor, the base of our bodies. Imagine that can absorb that very feeling I mentioned of being exactly in the right place at exactly the right time, knowing that you are safe here. You are among people who care about you, and you can allow yourself for just these few minutes to let go. Let's bring that feeling up now, almost like a car wash inside your body. Let's just bring that up. I always visualize the abdominal cavity like a snow globe. And if I could fill that with that light, let's make it liquid light that just could come up gently, passing past the small and large intestine, thanking them for doing their amazing job of knowing what to hold on to and what to let go. Imagine consciously thanking those organs for their job, asking it to retain what you need and release what you don't. Let's bring that line of liquid light now up around the stomach and the liver. Let's send your conscious intention to the liver, inviting excellent blood flow. You might even envision sparkly, like in the Disney intro to their movies, the little sparkles that come over the castle. You can envision that line of light just offering residual sparkles that now kind of collect all the way around the liver. And let's bring those sparkles up and put them all the way around your heart. And envisioning this line of light coming up around your heart and your lungs and filling you all the way up to the clavicle, your collarbone. Let's visualize now the entirety of your abdominal cavity full of this positive intention and this sense of being fully present here, knowing you are supported and safe, and your body is h operating in harmony with your intention, with your mindful presence, inviting every one of your cells, I just picture them, each one with your little face on it, turning and smiling with attention toward my voice and invitation to bathe your organs with love and bring that full intention for your highest good. Now, all the way up through your chest, back up the line of your spine, up the back of your neck, and passing by your shoulder blades where so many of us hold residual tension. Let's just send a little extra wave to your shoulders in thanksgiving for their job, for holding you up, supporting you in your efforts to do so much with your arms. Let's just envision like marionette strings. If we could allow that through your neck, just to be released, just invite your shoulders, just in your mind's eye, to let go with a deep inhale and exhale. We can just envision your shoulders relaxing and having that good sparkly feeling now coming up the back of your neck, coming around each of the sides of your your head, the occipital, parietal, frontal lobes, and now coalescing like a crown at the top of your head with all of that light coming together like a crown. And then I picture it streaming up and around you like a fountain and showering you with that very same intention to be bathed in your own wish for your highest good. Let's take in a couple more deep breaths to cement in the feeling that you've invoked here today. Knowing this is now permanently yours in your conscious and unconscious mind. You can call it up at any time. You know my voice. You can use it to embody what you need to hear. Let's wish your body well next time you come back to this peaceful and relaxing space, knowing that you're able to create what you need in the moment on an emotional level with mindful awareness of your body's present experience in time. So, as I count backward from three, let's bring ourselves back to conscious awareness of this space. At three, as you take in your body and contact with the seat and your feet on the floor. At two, as you take in conscious awareness of my voice and the presence of others in the room, all of us with our wishing our full intention for your highest good. And when you're ready, at one, to open your eyes and take in the light and the space between us. Thank you.