Pain

In this episode, hosts Richard Nicholls and Fiona Biddle speak with Dr. Rebecca Berman, a pain consultant with the NHS, to help explain the influence of perception and emotion on pain, the potential impacts of psychological trauma on pain experience, and techniques for managing pain.

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Transcript

Richard: 0:10

Greetings earth people! Time for another episode of Therapy Natters for you with Richard Nicholls and Fiona Biddle. The podcast series for anyone with a brain, a mind, and a minimum of at least one working ear. Although there is a transcription on the website so you can even get away without that. Hi there, Fiona! Here we are again then. Another episode, another

Fiona: 0:32

Another episode? Yes, what are we up to? 95! Gosh, feels like only yesterday we

Richard: 0:38

We're nearly up to 100. I know, but it won't be long, it'll be two years.

Fiona: 0:42

Yeah, it is nearly two years.

Richard: 0:44

It doesn't feel like we've been doing this for nearly two years, does it?

Fiona: 0:46

It, it really doesn't, and obviously we, we started having guests at episode 50 or 51. And it's, guest week today. We have with us Rebecca Berman, Dr. Rebecca Berman. Who is a consultant working in the NHS with pain. She also has psychotherapeutic training but doesn't do that specifically. It informs her work as a doctor, as a pain doctor. So you won't be able to get help from Rebecca. But we will because that's what she's here to natter about with us. So welcome, Rebecca, lovely to have you here talk to us about pain, psychologically, I guess.

Rebecca: 1:32

Gosh, talk about pain psychologically, yes. one of the issues that is a problem when people come to see me is that people want to distinguish between pain as if it's in their heads and if it's in their bodies, as if One is real and one is not. And I don't like to use that language. First of all, it feeds into stigma for a lot of patients. Oh, my pain is not real. and that's opening up a whole can of worms. But the other thing is, pain doesn't really work like that. We feel pain in our bodies. We do. If we didn't have a body, we wouldn't have pain. What we need to feel pain is to be conscious. And I think sometimes that is the source of confusion because pain is an experience. An experience is by definition something you have to be conscious to have. So, I'll tell people, yes, we have to be conscious to experience pain, but we always feel pain in our bodies. Maybe I should just give you a little working model that I find It's very useful when talking to my patients there is some evidence for aspects of this model but as I often tell my patients, it is only a model. It's a nice set of ideas and hypotheses that you can think about what we're doing that may be useful or less useful in individual people to determine how they're thinking about their pain and I'm thinking about their pain and what we're going to do about it. Now, if you can think about pain as, as I said before, is, is an experience, it's individual to us, it is subjective and there again we come on to this stigma between the Objective and the Subjective. And I like to think about it, it's our only way of experiencing the world is subjective. It's very, very important. The subjective is as important as the objective. So this is what we feel. It's one of the reasons I'm a little bit eccentric, is I don't like To give people pain questionnaires forms where they convert pain that they're pain to a number or a score. I don't find that helpful So if we come back to what pain is doing for us, if we think about the role pain plays in our lives, plays in the lives of other animals, one way to think about it is, is that it is a warning of something that is wrong within our bodies. Something we have to pay attention to, which is why it wants to get our attention. And it's a signal that there may be something the matter. So in the simplest terms, if you fell over and broke your leg, it's not great to walk around on a broken leg. You need to keep fairly still until that leg heals. So pain is a warning signal. Kind of saying, I suppose this is anthropomorphizing aspects of the nervous system which are completely automatic, but what that signal is doing is it's saying do not walk and it has a role in doing these things, that's an acute pain. But let's say you're walking down the street and somebody attacks you, I know somebody runs at you with a knife or something. You will go into your, your freeze flight fight mode and you'll probably, if you're sensible, run away fast. Let's say you're running away and you fall over and you actually do fall over and break your leg, break your ankle. In that situation the adrenaline, which is a very good, chemical for reducing pain will actually abolish the pain signal reaching consciousness or at least attenuate it to a higher degree and you will carry on running maybe doing more damage to your broken leg or ankle but once you're out of danger it's only then that you will feel the pain so these are automatic survival mechanisms that we're evolved to have. The issue therefore with pain there's a number of issues or one issue is that you cannot Switch pain off at will. You can't just say, oh, well, I know what that is. It's not gonna do me any harm today. I would ignore it because it's an automatic process. You know, if we were evolved to ignore it at will, that has no survival value. It's against survival. So that that's not an evolutionary mechanism. So we cannot do that. And then if we develop conditions that may be chronic but won't, may not do us harm if we can keep moving, in fact maybe do us more harm if we keep still, our nervous system's not going to allow us to ignore those sorts of pains and there's all sorts of conditions that may do that. And certainly there's a range of conditions where the actual mechanism that is feeding up these pain signals up into a conscious attention may be at fault themselves and there are theories about that and as I said I'm not a neuroscientist I don't want to talk rubbish on this podcast but there's certainly a number of conditions that produce chronic pain that actually is just unpleasant for us it doesn't add anything to survival value and if we actually could ignore those pains our life might be better and that's a gross oversimplification. So there's a lot of issues for those things that go on in the pain clinic. Now some of the ways that our bodies, including our nervous system, is controlling these pain signals is that we have what are known as descending inhibitory pathways that descend down from the cortex via various waystations, within the uh, base of the brain, the brain stem, down is the spinal cord, and these are modulatory systems. So they will let through more or less of signals at different times. Of course, we have similar systems for all of our senses, and often I will say to my patients when I'm talking about how this works is that, let's say somebody's sitting in a chair, I presume most people, well I suppose some people might be out walking listening to this, but let's say you're sitting in a chair, and I say to people, well can you feel your bottom on the chair? And most people, unless they've actually got some issue with pains from that area normally, are not aware of, of how that sensation is until I mention it. And that's normal. We block out most sensations. We block out a good deal of hearing, of vision, because otherwise our mammalian brains are not going to be able to deal with all that information. So when we're looking at mechanisms to maybe modulate, to control the amount of pain we're experiencing, we're looking at how we can perhaps affect those systems safely and to our own benefit. So normally one of the the simplest mechanisms is we have various attentional centers. So there's a part of the brain called the anterior cingulate cortex that is actually meant to function, or does function, as an attentional area. And the other thing is we can only pay attention to so many things at once. We've all got experience of that. I mean, in terms of multitasking, we can't really do a lot of things at once and pay them attention. So that means that sometimes when pain that's not too severe, distraction can work. You know, you can do a craft, you can be eating with people, you can be reading a good book or watching something on the television or working, all those things are distractions and they may keep certain pains at bay. But of course, we can only distract ourselves So much the times we need to rest. So it's not a long term solution. But these modulatory systems actually work at deeper levels than that. They can work in the spinal cord, for example, and they can actually even prevent those signals reaching this attentional area. And maybe that's one area that we can look at to begin to modulate pain. Now, I'm in a specialty where we've used A lot of medications over the years. We use medication, we use drug treatments, and that's caused us a lot of problems. So, a lot of drugs produce these modulatory effects by mimicking chemicals that our own body produces. So the endorphin mechanisms are a good case in point. So opioids have been around for ages and they're very good for acute pain. They can be used effectively in certain forms of, you know, pain from terminal illness, but when it comes to The usual chronic, pains that we would be dealing with. They produce a lot of problems. First of all, our bodies will produce physical dependence. There will be biochemical adjustments to their presence, so they will become less effective and you need higher doses for the same effect. Secondly, there is actually an addictive potential and that is actually quite high. And higher, I think, than people realized when they first started using these things for chronic pain. They produce effects elsewhere in the body because a lot of these chemicals our body is using, these are neurotransmitters and the body will use neurotransmitters in all different places to do different things. So the same neurotransmitter may have multiple purposes, so if you think about it, you can take a medicine and it will produce other effects. So the morphine type medicines, they will make you drowsy. They will affect the gut quite severely in many cases. They can actually affect the urinary system. They can affect the immune system, which is another modulatory system in certain aspects. And they can produce. A lot of effects and actually be very very harmful. They'll also produce affect a lot of hormones, too. So, overall, the number of people who are helped with these long term and useful ways is actually very very small. But they are working on these modulatory systems. We use certain forms of antidepressants in the same way that will work in other modulatory systems. And you say, well, why are you giving an antidepressant? Is it because you think pain is associated with depression? Well, yes, the pain is going to affect your mood. But actually, it's the same principle that certain chemicals that might be working on the mood system system, another modulatory system, where we also be working on these pain systems. So a medicine that's been around for a long time is called amitriptyline, it's a very old fashioned antidepressant, and it's not used much for treatment for depression now, but when we use it in pain, the doses we use in pain are a fraction of those. that proved effective in in depression which shows that they're working in a different kind of way. But again, a lot of side effects from all these medicines. the idea that we're going to reach some holy grail where there's going to be a drug or a chemical that's gonna somehow abolish pain and leave everything else intact. It's all gonna be wonderful That's not gonna happen. It just doesn't work that way. So we're beginning to move to other ways of managing things In fact, we haven't advanced as far along as As I would have liked at this stage, but I suspect those ways of looking at things hold out a lot of promise for the future. So, if you think about these modulatory systems that we're just bunging some chemicals to try and help producing the problems we have. Well, those are fine tuned systems. And then it comes back to what we think about what pain is doing. So if we go back So we're talking about it, it is this warning, this safety system, and therefore, if you think about, well, if we are altering the way our bodies are perceiving these signals, again, that's using almost anthropomorphic terms for things happening at an unconscious level. And when I say unconscious, I'm not talking about the subconscious, I'm just talking about an automatic level within the embodied nervous system. So when we're talking about Things that are working that way. What comes back, well the opposite of pain being a dangerous signal is, is to feel safe. So if we feel bodily safe, that is actually going to modulate our pain, reduce our pain. And that may well be where we're looking at the future for this. So just to go through perhaps a couple of aspects of what that could look like. So one thing I've been interested in for years is placebo, placebo mechanisms. And that has a bearing on this. Placebo was seen as something that got in the way of drug trials. Often it was seen as something that, oh, that person is suggestible, they're getting a placebo. And again, there was a, almost a stigma attached to having a placebo response. But the thing is, placebo responses are completely normal, healthy responses. And you see similar responses in animals. And again, these are modulatory systems, and they're about regulating how much energy an organism is going to give towards various aspects of healing, for example. So, there's an experiment I believe was done with hamsters many years ago, and they had two lots of hamsters, and they put one lot of hamsters in a light pattern, artificial light pattern that was for a winter pattern and one that was a summer pattern and I think they gave him some kind of minor infection or something that the hamster wouldn't actually heal from and the ones in the winter pattern took longer to heal than the ones in the summer light pattern and the interpretation of this is that in winter there's less resource so if an organism is detecting that they're in a situation with less resource, they will give less resource to healing. They still want to heal, but they'll give less resource to that. So there's the modulatory systems. Now, if you, if we think about pain, and again, maybe some of my logic will get a bit back to front and apologize, but there are principles here. So if we look at uh, social animals as animals, will look after themselves. So let's say you are part of a society, a social animal, as of course we are, and that's If an animal of a group is being looked after, that produces a safe environment and safety is again, is a resource. I suppose it goes back to hierarchy of need. Safety is certainly a resource. And in a safe situation, These systems will produce a modulatory effect and pain can be reduced. So we see that. Now for animals that have sophisticated methods of communication, as we do in particular forms of symbolic communication, it may be that something seen as an act of care from one of your fellows will have this same effect. So, you go to your doctor, your doctor says take this, you'll feel better, and you will feel better. Because that is what's going on, it's an automatic process. I'll give you an example from myself, I had an ear infection almost exactly a year ago, very painful, kept me up at night, so I thought, oh, I need to go see the doctor. As soon as I got to the doctor's waiting room, Even though I still had the infection the pain went for the first time in two or three days because I was in a safe environment. My expectation was I was going to be treated, I was going to be made well again. So that's what safety can do and what placebo may be. But of course, if we are living in a environment that has its dangers and that can be deprivation or all its forms, that again will mean that in that situation, or if we are assuming that the symptoms we have are a sign of great harm, then that may alter these mechanisms that will let more of these signals that form the pain signals enter consciousness or at least get up to the attentional area and be competing for consciousness. So that is again an important mechanism. It just brings me on to the last thing before I stop talking. One of the things that we see in in our clinic, a lot of people we see have had psychological traumas, be it severe adverse childhood events which would have gone on repeatedly, things that may have happened as adults. And if you think about that, well, in that environment things are not safe you can imagine our nervous system's going to adjust to that. And we know, you know, for psychotherapists, you know what you'd be looking for. Often you're seeing people who may fear change, may be a part of that. It may be a heightened suspicion of other people, and often I will be seeing people who will have reduced their lives so they've become very limited, to the extent that they may almost never go out of their own room. So people could be leading very limited lives. They're not moving very much. They're staying in a room. They're not having much social contact. They don't want to go and meet new people. And the lives become really very miserable for them on one level. But on the other level, there's safety for them. So you've got this paradox between being safer, but unhappy. So that's quite a frequent thing we see and that's about, I suppose, an automatic modulation of external dangers. And I like to see, and again, this is my idiosyncratic way of looking at it, and it may be pulled apart by neuroscientists and philosophers and psychologists and psychiatrists, so please don't, well, don't quote me on this, but the way I like to look at it is saying, well, If you, for whatever reason, if your nervous system externally is responding to a heightened sense of danger, internally that, an internal heightened sense of danger may come out as being increased pain. So often we see widespread pain syndromes in people who have had these difficult, childhoods, difficult events, maybe as, as an adult. It's not the only thing that will affect the nervous system in this when producing generalized pain effects. It's not the only thing by a long run, but it's something that I think we see that is going on. So that is my little take on some aspects of what we do. It's a gross over simplification. Like I said, a lot of these things are only just models that may be useful to some people and not to others. But it is I think. at least in some people, a useful way of seeing the world. I'm going to stop there.

Fiona: 20:06

Thank you, and we do a lot of oversimplification on this podcast, so that's, that's great. I mean, it's really, really helpful to see it that way. I mean, I've got, I've got a question. This is more for sort of everyday pain not for the people that you were mentioning there towards the end of the, with the adverse childhood experiences, etc. But it's whether you believe that by well, is there a way of increasing that modulation effect by talking to the unconscious mind? So, I'll give you, I'll give an example. I get lower back pain quite often particularly if I'm walking any distance. But I will sort of talk to my mind and say look, I'm going to walk to X anyway, so there's no point in you giving me any pain to experience because I'm going to do it and we also, we, that's the whole of me, knows that it's not actually dangerous, that it's good to walk, It doesn't take away the pain completely, but it does seem to have a modulating effect. Does that make sense to you, Rebecca, as I

Rebecca: 21:21

does. Yes, that, that, that makes sense. And so I realize I'm still in danger of distinguishing between things that are seen as physical and non physical. So, of course, all these things are physical. As I said, we don't have bodies, we're not going to have pain, but let's take an example. So, if somebody comes to my clinic and they've got an arthritic hip that hurts to walk on, and in fact the more they walk on that maybe they will do some more damage, but that's bothering them. Well, what I would normally do is I would send that person off to see my orthopedic colleagues, who will give them a new hip. I Do see people who have arthritic hips, and for other medical reasons, they can't do that. And that becomes actually, is quite a difficult thing to modulate by other mechanisms. But back pain's a different matter. I mean, there our spines at every level. There are three Joints at every level. I've got 33 vertebrae, I think, but I should know that now as a pain doctor. But, but let's say in the lumbar spine, there are five lumbar vertebrae, and let's take normal to normal lumbar vertebrae. So the bottom one is normally the fifth one, the L5. One above that it's L4. There's a big disc joint at the front, which acts like a shock absorber. It's got a fibrous ring, a sort of, a pulpy interior, and it's a bit like a tyre on the side. And that ring's got nerves into it. Behind that, forming a ring around the nerves in it at the bottom of the spine, there are two other joints called the facet joints, and they limit movements, and they also give some protection to the contents, the nerves in the spinal canal. So every level you've got this thing I suppose a bit like a slightly I suppose they're like a tripod with big springy legs that gives you a bit of movement but also gives some stability. And as we get older, you know, we may get some changes in the disc, we may get some arthritis in the facet joints and they may be sources of pain. But then what those are going to do often the muscles in the back, these huge muscles, postural muscles in the back, may increase in the muscle tone. to try and splint that a little bit and you end up getting a lot of muscle pain. We also see people where, younger people often, the joints themselves are looking fine but they've had an incident where the muscle has gone spasms and not quite released. And there is some old evidence that a lot of back pain has a muscular origin whereact the back muscles are not relaxing. And of course For us as individuals, we can't tell what's going on in our back, you know, you can be, I suppose, the cleverest spine surgeon in the world. You still can't tell, really, just from what you're feeling in your back, what's going on in your own back. We can't tell that, and for me as a doctor, I can look at all these scans, I say, oh we've got this, you've got that, but it doesn't translate necessarily into what our conscious experience is. But I can tell people, I say, look, you've got these things in your back, but you've got to keep moving, it's safe to walk. Now one of the things that we do, and it is important to keep moving, and I've gone about this, I suppose, in a rather long winded way, for which I apologise. If we can say, look, we know there might be things in your back, but it is safe to walk, you need to relax your muscles, so using techniques I presume from hypnosis more, which can be simple techniques, they can be imagery techniques, relaxation techniques, I think, can be very useful. Certainly you can use things like progressive muscle relaxation exercises where you, as you breathe in and you breathe out slowly and relax your muscles you can begin to learn with the rest of your body, which doesn't go into the spasm, to begin to have really relax the muscles and then when you've got heightened tension and eventually, hopefully that will feed into your low back so that can be useful and I often teach people to do some imagery relaxation imagery they can imagine themselves in a nice place wherever they may be so they can bring that to the fore in a single breath. And so if they're feeling they've got a lot of pain, they can reduce that.'cause people often say, well look my as they say, I can do that when it's not too bad. When it's really bad, it's much harder to do. Which of course it is and it's not always going to work. But I say to'em, if you practice these things gently and it has to be gentle practice'cause. If you force yourself at it, that's literally going to make you uptight. It's not going to work. But you can get used to doing these things. So when you need them, they are almost automatic. so it's that expression, it's second nature. You produce things in a natural response. And of course, we do this all the time. Learn a new activity, be it a sport, learn a new language, you know, we can produce something until it becomes automatic. The analogy I often use is, for me as a doctor, there's various things that we may need to do in an emergency, that'll make us go away and practice, a non emergency,'till they're second nature. So I say to them, you practice these things, so when you need them You can just do them automatically without thinking. And I think the without thinking is really, really important, because you think about aspects of hypnosis and about having higher order thoughts, you know, thoughts about thoughts, somatic cognition, somewhat depressed, so things are working at a lower level than that. I suspect there's elements of that that are important to producing these effects to where they become automatic So I think things like a lot of relaxation exercises, imagery exercises. These things are helpful I mean, there's a lot goes on with CBT for pain and what have you and your CBT can be very useful about how people regulate their lives and your negative thoughts, etc But that's often this element missing for a lot of what people need, and I think it's producing this almost automatic bodily response. And often I use analogy, you know, I suppose the analogy of creating new pathways, which is I suppose actually what it's doing within the nervous system. So I think imagery, Breathing exercises often we're sending people off to do things like Tai Chi because the idea of Tai Chi and some of its more limited forms is it produces, I would say, a feeling of flow and to feel flow is a sense of feeling well. And you can alter any movement to the point where it doesn't hurt somebody. If it hurts the stand, they can do it sitting. If doing a wide movement with their arms is painful, they can do a small movement, to the extent they're virtually not moving at all. Because there is evidence that even thinking about a physical movement will produce measurable changes In the body. So doing things that have that, that feeling that they're just flowing automatically even initially as in Tai Chi or eventually as in learn progressive muscle relaxation and imagery exercises. I think the things that we can all do and I suspect as the years go by we'll become more sophisticated in the ways we teach those and the evidence we collect on their effectiveness.

Richard: 27:58

That's wonderful. Everything that you say makes so much sense. I recognize, and I, I know this as a therapist, I've been working as a therapist for 20 years, but only as a psychotherapist for a few, really, a lot of stuff in the past was only hypnotherapy, so people wouldn't seek out hypnotherapist for deeper, deeper issues. But the times that people would've come to me. Even in the distant past, because they wanted to learn some relaxation stuff through hypnotherapy, maybe they got migraines. That was a common one. People will come with migraines. And so many of those clients might have had difficult experiences growing up that would have led them to not feel that they've got a sense of belonging. They didn't feel that they fitted in anywhere. And I know correlation doesn't imply causation, and I'm filtering through my memories a little bit as well. I'm just picking out those that fit the narrative. But, I keep seeing it. That's so many people with pain. issues have had a lot of difficulties, and if we can encourage that sense of belonging, if they can feel that they fit in, within the culture that they're in, within their friendship group. Because it's one thing to have, say, ten good friends, but if your foundations that developed when your personality was being developed are, there's something wrong with me, I'm broken, nobody likes me, nobody loves me, I'm not deserving of attention or affection or love than even as an adult with 10 close friends. They're not going to feel that those friends are friends, if that makes sense. And just having that, knowing that that can increase the way pain is experienced, it explains a lot about fibromyalgia, I think. When we do find a lot of people with fibromyalgia, chronic fatigue syndrome, a lot of them would have had, not everybody, not for me to comment for definite, but a lot of those clients would have had difficulties in childhood. All of this exaggerating how they experience pain, it all makes a lot of sense, Rebecca, it really, really does.

Rebecca: 30:10

Yeah Talk about fibromyalgia. I wouldn't call myself an expert in fibromyalgia at all, so I don't want to say things that are wrong. But, Fibromyalgia was initially, there was given a definition, I think it was the American Society of Rheumatologists, I think that's right, and then they've modified it recently, and I don't know the ins and outs of the Modern definition, but it was physically people meant to have a number of tender muscle points, but the symptoms were widespread pain fatigue and poor sleep. Now the thing is there are a number of theories about fibromyalgia and they They're not mutually exclusive So for example, there is a theory that it's produced by what are called active antibodies. You have a viral infection, you produce antibodies, and they actually work almost like neurotransmitters in your pain system and kind of disrupting it. That's one theory, for which there is actually some good evidence. You know, another theory is, well, some of us more pain signals get through than for other people, whatever that means. You know, we're all different, just genetically. Of course, there's truth in that. And of course, there's this other theory of particularly adverse childhood experiences, watching how the nervous system is responding. And they, again, they're all early theories, and some of them have got more evidence for them than than for others, but I would say that, widespread pain and fatigue, poor sleep, these are common human experiences. Our nervous systems and our bodies react in certain ways. So to get these symptoms. A lot of things could produce these things. So if somebody comes along with a symptom, I don't make an assumption, well, I know what's going on with you. And even if they've got, history of adverse childhood experiences, it doesn't necessarily mean it's the main factor producing their pain. And this brings me on, just onto the thing about uncertainty. We don't know a lot of stuff. We don't, as doctors, we don't know a lot of stuff. As human beings, we don't know a lot of stuff. And this whole business of being okay with uncertainty. It's my job to make sure that we have investigated everything as well as we can, either myself or by referring to colleagues with more knowledge in certain areas. But it's also my job to be able to say to people, look, we've done everything we can. This is the limits of our knowledge and now we've got to cope with what we can. So chronic fatigue, for example, obviously now with long COVID, there's a lot more chronic fatigue and other symptoms being seen, which we still don't fully understand. But there are theories of chronic fatigue that have, a very physical substrate, biochemical substrate that may be amenable to particular treatments. So to say somebody with chronic fatigue, well we're going to put it all down to adverse childhood experiences. Well maybe we can put down a lot of it and maybe we can't. I think what we have to do is we have to treat people with the limits of our knowledge, the limits of understanding and do what we can do. But it's always wrong to make assumptions because that again comes to being judgmental and you know as human beings we are quite judgmental. I mean, I suppose I've done my personality profile and it says I'm not particularly judgmental. But that's because I don't really believe in those personality profiles. Oh, God, that's a can of worms, isn't it? But, you know, but I think I'm very judgmental. I think I'm very judgmental as a human being. And again, if you're a therapist, it's what of yourself you bring into the room. And I bring all my prejudice in, and I've got to be, I've got to watch out for those. So that again becomes, as a doctor, you know, it's why it's good, I think, for doctors to have more self reflection and perhaps have some proper supervision about the things they say to patients. And even in the best of my intentions, I sometimes get things, I misjudge things, and I end up with bad miscommunications, and, and, and afterwards I'm mortified. I thought I've explained things very well to somebody, but obviously they've gone away very upset with what I've said. It happens not very often, but it does happen. You know, I'm a human being. My patient's a human being and, and, and, and communication I is imperfect. Anyway,

Fiona: 34:09

That's a very important point. This communication is, key, but we're not perfect. And it's between two people, two individuals, no two individuals ever going to replicate any other two individuals. So the things can go wrong. Absolutely. But it's, it's recognizing that state that's So critical, isn't it?

Richard: 34:31

Rebecca, wow, you, you brought so much to the episode today, and genuinely I'm gonna struggle to try and edit this down to the 30 minutes. So I suspect this one's gonna be a slightly longer episode this week. So I hope everybody's stuck with us. I, I expect they did because

Fiona: 34:46

I'm sure

Richard: 34:46

been so helpful. Yes, thank you. So, we need to, we need to wrap up for another week. We will be back next week, because we've got nothing else to do. We're always here for, for now. Anyway, we might have a little bit of a break, have a little season break at episode 100, but for now, you know, we're still gonna be here. So, tune in next week, where we'll be back. Don't know what we're talking about next week, we'll deal with that then. In the meantime, if there's anything you want to ask us, to follow up from this episode or any of the other ones, get in touch! There's a form on the website. Let us know how you're thinking and feeling. And if you subscribe on an app that allows you to leave a review Why don't you give us five stars? You know you want to. Right, love you and leave you, everybody, and thank you again, Rebecca, from the bottom of my lower back. I appreciate everything you said. See you all next week, everybody. Bye now!