We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. I'm Barent Walsh, PhD. I've been a self-injury specialist for over 30 years, written three books on the topic. It's been a major part of my professional identity. I'm primarily a clinician, and I've done clinical research, but I continue to work with people who present with self-injury and suicidality, and they've been people to whom I've been committed for my whole career. Thank you, Barry. My name is Janis Whitlock, and I am a, well, at this point, I'm a consultant. I work directly with schools and other youth-serving institutions around issues related to self-injury and suicidality, as well as resilience and connectedness. I'm here because I've spent the last 25 years prior to retiring as an academic studying self-injury. And Barry and I know each other quite well, didn't expect to be studying self-injury, but that is what happened. And 25 years later, here we are, still doing what we can do to make a difference in the world. And yeah, I think that's it. Just somebody who's educator, a change agent, and researcher. So, Barry, are you ready to kick us off? Yes, I should make one more comment. For many years, I was the executive director of an agency called The Bridge in Central Massachusetts. And I mention that because we established many community-based programmes for people coming out of psychiatric hospitals and state hospitals. We were part of what's called in the United States the "deinstitutionalization movement." So that was my background, working with people with fairly significant challenges and enabling them, supporting them, fostering them to live in the community successfully. Well, I'm really grateful you started us there because, I mean, we decided when we talked about doing this talk here today that we would basically look at the past, the present, and the future of self-injury. And so much of the past, the very beginning of it, for me, was flavoured by your treating self-injury book and just your presence. Between you and Wendy Lader, and Saif, those were the only two places that I could give as recommendations for people. So let's start talking about where all this started. What do you, Barry, mark as the origin of this field, and what were the key events that started all the research? Well, the key contributors way back in the seconds was Karl Menninger and a book called Man Against Himself. He was a psychoanalyst, and he viewed what he called the prevailing term at the time "self-mutilation." He viewed it psychodynamically. And he basically viewed it as a compromise between the death instinct and the life instinct. And he viewed self-injury as at least somewhat of a positive because it was fending off profound suicide urges. The field has moved on from that particular view. But that was an early influence in the 1930s. But by the time I was working in the field in state hospitals, we were dealing with what we still called self-mutilation. And the assumption back then, we're talking about the late '80s, was that self-mutilation only occurred in people with serious mental health problems, living in state hospitals or residential schools, or very intensive outpatient therapies. And then this woman came along named Janis Whitlock, who totally shocked all of us with findings about self-mutilation in a completely different population. I guess this is the sign to pass it to me, eh? Self-mutilation, I remember when I first-- I was first exposed to self-injury through my personal life because a couple of friends had kids who I had known as children and who were now self-injuring. And before I was an academic, I worked with women and high-risk youth or youth in high-risk settings. Otherwise, in other words, as well as I had been a foster mum and I just had encountered everything-- sex, drugs, food. I mean, I got all that, but this didn't make a lot of sense to me. And so it captured my attention, especially since it was coming through my personal life. And then I went to the literature. I'm like, what do we know about this? Why have I never really heard about it? And I started asking my friends who were in the front line, they were physicians and they worked in schools and so forth. And I was like, are you seeing this? And they were shocking me with their estimated prevalence rate because they say yes to a person. They all said yes. And I was like, how much? And I remember my paediatrician friend who had an adolescent clinic every Friday said, well, I guess about 10% of the population. I was like, 10%? That's shocking. So I started to deep dive and was just kind of blown away by how thin the research was. So I found your book, I think. Where did that come out? When did you-- That's what I thought. Yeah. Came out in '87. Right, it was Armando's book. Armando Favazza, Body Under Siege. And then a paper that he'd done with Karen Conterio on females who self-injure. And that was the only epidemiological study I could find at all. And that was not really, and it was very much a convenient sample, a very skewed sample of how they did it. So we had no way to estimate how prevalent this was. And yet I had friends, professional friends telling me that they were seeing a lot of it. So I was like, damn, I'm going to have to do a research project. And I thought it'd be super small, and it ended up being both Cornell and Princeton in that first two college study. But we were able to get a really solid epidemiological design because both universities were seeing it and had no information on it and really wanted to understand it. So Princeton called us, and asked if they could be involved. And the institutions worked with me really well to make sure we could draw a random representative sample, which is really important in epidemiology research to do that. And so that was that. And I never, and you and I were talking about earlier, I just could not-- I just couldn't wrap my mind around the rates that came out of that study, because we found that 17% of Cornell and Princeton students had self-injured ever in their life, which seemed really shockingly high. These students were attending elite Ivy League schools. The idea that larger percentage were cutting their bodies and were that distressed, for people like me who are used to dealing with state hospital populations, we were entirely shocked by your findings. And then that led to that whole explosion of understanding a whole different population, which you can comment on. Well, I mean, that led to me going, we need research on this. Like who's out here doing stuff? And at that point, there were a few people I was able to identify, a few people around the world, I think we-- so prior to not being an academic, I was working in the field as an educator. And my first instinct is always, who else should I be talking to and who knows about this. So that's what led to a desire to do conference papers. But I couldn't hardly find anybody to do conference submissions with. But I did find this handful of people around the world. I think we had 20 that we were able to identify who had ever done research on either self-mutilation, self-injurious behaviour, or then later we came to call it non-suicidal self-injury. But at this point, we're still in the-- I think we left the term self-mutilation behind, and we were working in self-injurious behaviour or SIB. And then we started and then I invited whoever I could find to a conference or just to come, have a few days at Cornell in 2006. And that's where you and I first formally met and people came together. And by then, the research was just getting going. And wow, it just has taken off, hasn't it? Yes. A little bit about terminology. The term self-mutilation, we jettisoned it because it was inaccurate. About 85% to 90% of people who self-injure do a level of damage that doesn't require medical attention, they weren't mutilating the body. The term self-mutilation was pejorative. It was judgmental. It also was inaccurate. So we moved on to different terms like deliberate self-harm and parasuicide. They had their own problems. In fact, just one comment, a common term used for non-suicidal self-injury is self-harm. There's problems with that. It's nonspecific. I just went to a conference in October, the American Foundation of Suicide Prevention. There were people there, noted scholars, using the term self-harm. One of them, and when using the term self-harm was actually referring to non-suicidal self-injury, cutting, burning, skin picking, and the like. Another person used the term self-harm, a noted scholar, and it included not only cutting, burning, picking, but also eating disorders. So it's very confusing, the term self-harm. That's why we're grateful when our scholar colleague Matt Nock at Harvard came up with non-suicidal self-injury, which tells us in the term it's not about suicide, but there is tissue damage, there's self-injury. And that's been the preferred term in the field ever since. Yeah, but it does point to, well, it points to two things that were really funny. One is out of that 2006 meeting, there was a group that was going to take on that term, like terminology issue. And it was, I think that it took six or seven months for them to come up with that. I think I was on that group. I shouldn't say them, but I can't remember. But that group took a long time to come up with the term, and partly because there were different opinions about what term should be used. And Matt had floated nonsuicidal self-injury. And I think the majority of us, but not everybody, was like, yes, that's very specific. It helps us to really clearly differentiate non-suicidal self-injury from what can look-- its cousin, basically, a suicidal gesture of some sort. But we have to also acknowledge, and I think this is a nice segue into our next question, which is what have we learned in that time, one of the things we have to acknowledge is that self-injury does have a complex relationship to suicidal thoughts and behaviours. And it is part of a larger constellation of self-harming behaviours that are not specific, like disordered eating or risky driving or substance use. And it fits in there too. But I agree, this terminology challenge has just been fully persistent, and it doesn't help that it's different across the world. So, Barry, tell us what you think have been the biggest contributors, the biggest breakthroughs since we started everything in 2006-ish? I would say there are two, although there's certainly many other. But first was the differentiation of non-suicidal self-injury. And the way I speak about that when I do trainings on this topic is that what's suicide about? What's the intent? My understanding of the intent, it's largely about ending misery, perhaps permanently ending misery. And it's about death, escaping unendurable pain. Self-injury is, it has a different intent. It's an affect regulation behaviour, primarily. It turns out it does work in the brain when you damage yourself, when you cut yourself, and you stop, that not only is the physical pain relieved, but the brain is tricked and emotional pain is relieved as well. So you've got suicide focusing on ending misery, and self-injury is primarily about reducing intense emotional distress, but still surviving. Secondarily, self-injury is about changing other people's behaviour, getting a reaction from other people. But first and foremost, it's an affect regulation behaviour. So that would be the major distinction clinically that I think is foundational. And the second thing I would say is then within the last 15 years, major researchers like Nock, and David Klonsky, and Jennifer Muehlenkamp, and probably yourself, have shown that persistent self-injury is often associated with subsequent suicide attempts. So the behaviours do have a link, particularly with people who become involved in self-injury over time, have done it a lot of times, may have multiple methods. So what we've learned is that people who present with self-injury, particularly if it's persistent, we need to assess whether they also have thoughts of suicide in addition to their self-injury. And if they do, thoughts of suicide would entail using a different method. Yeah, I love that you pointed that out. And I also peg that the relationship between NSSI and non-suicidal self-injury and suicide as being a really important outcome of the research over the past couple of decades because especially, as you know, from a clinical perspective or an institutional perspective, when I work with schools, people want to know who do we really need to worry about. I mean, you want to worry about care for everybody, of course, but some are at uniquely high risk for other really adverse outcomes like suicidality. So trying to figure out how to differentiate those two groups was, I know it was one of our key agenda items. We did a longitudinal study trying to figure out how do you ferret that out. And fortunately, it does look like there are some pretty clear markers related to how much people self-injure whether they're using a highly lethal type to self-injure, whether they use multiple forms to self-injure, whether they have hopelessness and so forth. So you can ferret people out. And then there's that whole group of people who self-injure and don't ever even consider suicide. It just doesn't even come into their mind. And one of the major clinical implications is for people who have relatively minor self-injury with relatively short courses. It's an inappropriate diagnosis to have them admitted psychiatrically to a hospital for superficial self-injury. You're hospitalising them for affect regulation behaviour, and that can produce a whole course of negative repercussions because psych hospitals aren't exactly pleasant experiences. So the clinical management has put a great deal of emphasis on regular common self-injury versus persistent ongoing self-injury, which you need to assess as to whether there's also suicidal ideation and planning. Exactly. And that's one of the-- I do a lot of work with schools around that because a lot of schools don't-- they put NSSI in their suicide protocol bucket, which is, as you just said, it's not only not ideal, it can be harmful in some cases. So having clear, separate protocols are really important, even as you acknowledge they will intersect in some ways. Because, for example, we do know that even though the research is very clear on the fact that NSSI does not lead to suicide, it is not a pathway factor, it does make it easier, psychologically, it looks like, to take the steps to carry out a suicide because you have experienced damaging the body. And it's not easy to figuratively and literally slice through layers of internal and external prohibition. But once somebody knows how to do that, even though, as you said, I find the same thing, they don't use that method at all, but they know how to hurt the body, then it's psychologically. That is not one hurdle they're going to have if suicide becomes an option. Yeah, for example, Jennifer Muehlenkamp in a great podcast she did for ISSS, the International Society for the Study of Self-injury, she reported, she did a scan of the entire literature, and she found that 25% to 30% of those with NSSI also had suicidal ideation and perhaps attempt. That means 70% to 75% of people who self-injure do not have a suicide trajectory. So it's not an automatic progression. In fact, it's actually a somewhat unlikely progression. Right. If somebody is using it pretty consistently and effectively to self-regulate. So there does seem to be some different trajectories. One just kind of self-injury just becomes or you symptom swap with something else to stay fairly regulated. And another, it doesn't work well enough, you can't return fully to baseline. And eventually, suicide becomes an option as just-- It might be an appropriate time to mention the evidence-based treatments that have emerged over the course. And frankly, those are dialectical behaviour therapy and cognitive behavioural therapy. And Cassie Glenn, a student of Matt Nock's, did an excellent article in 2019 reflecting on the evidence for effective treatments. And she found that DBT was the one with the most randomised clinical trials indicating efficacy, and CBT came in after that. What does DBT do? It teaches people systematically emotion regulation skills, distress tolerance skills, mindfulness skills, and interpersonal effectiveness skills. As I said, the main reason people self-injure is affect regulation. So logically, in order to decrease or eliminate self-injury, people need to acquire other ways to regulate their emotions, to deal effectively with people. And Marsha Linehan, the originator of DBT, put a great deal of emphasis on mindfulness, full attention in the present moment without judgement. CBT, which focuses primarily on cognitions, also has been found to be one of the most evidence-based treatments ever developed in the field of psychology, and it too has been used to be very effective in reducing self-injury, and for that matter, suicidality with different emphases. Thanks for mentioning that. The only other thing that in terms of-- where I feel like we really did make some good contributions, well, there's been a number of areas, I shouldn't say the only, but one of them is social media. The link between social media and NSSI, because we are all starting this research as social media was really coming into play there. There was just this constant question of, well, how is this all interacting? And I think there's been a lot of really excellent research coming out of a variety of different labs, think of Stephen Lewis, for example, and a lot of the work that he's done in that area. And we did some early work in that area out of my lab, too. And I think one of the big takeaways-- there's a lot of takeaways, but one of the big takeaways there is that social media and the places that people find themselves in social media are related to NSSI can be supportive if they're supporting the healing process, if there's a community element to the question of how do I move my way out of this behaviour and use something else instead. That seems to be, it doesn't always do damage. The other thing, though, is where it can do damage is where people tend to mix, they mix up their behaviour with the sense of belonging and community that can come from social media. And now you have self-injury linked to a sense of community affiliation and belonging. And that makes it harder to stop and to leave the community. So there's been a lot of nuanced findings in that area, but something I think has been really helpful in terms of thinking through prevention models, too. Well, I've always thought of your Cornell self-injury website that you started as the most helpful one to help people who are self-injuring. It's prescriptive, it's specific, it's research-based. Unfortunately, there are websites and other platforms that show videos of people self-injuring, glorify or sensationalise self-injury, provide literature, articles, poetry about self-injury, all of which have been found to be very triggering content that is likely to result in more self-injury. Some people delight in that. There's an odd world of people who are rather pathological. But thank goodness the Cornell website and a few others were out there to help people recognise they have a problem and provide some suggestions about what to do about it. Well, thank you, Barry. It means a lot to me that you should say that. And, yeah, we're working on it. I mean, I feel like we can't-- none of us, I don't think any of my colleagues or I can produce helpful content materials fast enough, especially now. I mean, I get questions about NSSI and AI, for example, and I'm like, well, we have-- it's just things are moving so, so fast that it's hard to keep up. But the one thing I do, I do think is really unique about or not unique but interesting about all the research we've done is the consistency of function, like you said, the role of self-injury and regulating affect, feelings, is unequivocal and very well determined. And we never find anything other than that, really. Other than communicating with other people. But it all has to do with affect, so fortunately-- Speaking of that-- sorry to interrupt you but you and I talked about this before. As a clinician, my favourite question to ask somebody who self-injures is not why do you do it. That's a poor question. My favourite question is, what does it do for you? Because that's an open-ended, non-judgmental question. And I ask people who do a wide range of self-injury, superficial scratches with a paperclip, to 10 cuts with a razor blade, to people who do major damage such as 20 sutures on a limb or even genital self-injury. And, what does it do for you? And what's quite intriguing is I almost always get the same answer. They say it gives me relief or it gives me release. So the researchers are onto something when they say this behaviour is largely about affect regulation. The verbal reports of the people who do it echo that by saying, it gives them relief and it gives them release. The helpful treatments teach people other ways to regulate their emotional distress. Barry, you just reminded me of something that I really love for you to talk a little bit about. And that is the concept of respectful curiosity, because I find that it really-- I teach it all the time when I'm teaching anything about self-injury, especially related to how do you have functional, productive conversations. But the concept has gone over really, really well in all the communities that I work in. So do you want to talk a little bit about what that is because it made a big difference. Respectful curiosity means you don't judge the behaviour. When you encounter it as a clinician, an educator, a parent, it's not helpful to show shock or recoil. Respectful curiosity is I'm going to sit here, I'm going to be with you, I'm not going to judge you, but I am going to ask you, what does it do for you because I'd like to sit here alongside of you, understand what's going on, and who knows, maybe we could do some joint problem solving. And respectful curiosity is really about being compassionate, dispassionate, and genuinely curious about what does this behaviour provide you. I really want to understand this. And if you're receptive and open and non-judgmental and compassionate, that's the groundwork to start work. I think that it really resonated partly because so many people who self-injure do worry about shocking people or having be overwhelming for someone. So when we're teaching professionals how to stay calm, to have to be in a dispassionate, calm, grounded state, and to make sure that your meta communication is all part of you are conveying fundamental respect for that young person or that person's personhood, that they're their own expert, that you're asking with authentic curiosity, openness, and saying, it's not too much for me. You're not going to overwhelm me. It's OK, I can handle it. That seems to really make a big difference. Yes. By the way, a related topic is one of the most unfortunate judgments that people pass on self-injury, as they call it, attention-seeking. That's completely unhelpful. It's completely inaccurate. And to use such a term insults the person who's self-injuring. Oh, you're just doing it for attention. You're trying to trick me into giving you some sort of attention. That's an unfortunate, inappropriate response. It's about relief and release, and there's tissue damage. We shouldn't judge it. We should be empathic and we should elicit an understanding. I totally agree. And I used to say, I have a lot of teachers say that, and I'd say, well, I don't know, that doesn't make sense to me in a lot of ways. But what else does somebody need to do? They clearly beaconing they need something, some care, some TLC. I mean, why would we withhold? That just doesn't make any sense to me. But yeah, I'm with you. All right, Barry, tell me where you think the field needs to go from here. Well, Cassie Glenn in that study of what's been effective with self-injury, one of her recommendations is more brief treatments and also treatments provided electronically on the internet. There are a lot of people, and you reported this a long time ago, high percentage of people who self-injured, they don't seek treatment. You did find that in your population, right? Oh yeah, I did. And so that's two possibilities that Cassie raised. But one of the points that I shared with you before is these skills-based treatments like DBT and CBT, they teach skills and the request is that these people practise these skills between therapy sessions and become adept at them. One of the frustrations in being a therapist is we often find they don't practise the skills, or when they get flooded emotionally, they don't use them. So one of the challenges is how do we foster greater use of the skills we know are likely to work if they implement them. And one of the things that you and I talked about and I share, I think we share a common approach is, skills should be taught compassionately, collaboratively. Let's do the skills together. Maybe I'll communicate with you between sessions asking how is your skill practise going. Let's make it a shared problem solving, a shared dilemma. Let's not scold if you don't practise skills. Let's, in fact, maybe the terminology has become worn out. Let's call them tools or things to do, or what you want to do to solve this problem. So I know you have a lot of thoughts about this too. So many. But I think what you said is just absolutely perfect. I also love that when you sit down, you can work with young people or any people of any age. I do tend to work with young people, so I reflexively say that. But think of all age groups. There's lots of really innovative things that somebody can come up with potentially wanting, being willing to try. And it doesn't have to be like, you can use different sensing preferences. For example, we know if somebody self-insures, they're probably somewhat, at least somewhat somatically preference. They probably like to feel things on their body. So are there ways, are there cloth, or things they can squeeze, or stuff that they can go out, or they can go out and feel the wind on their skin. I mean, there's a lot of different things I found that people are willing to try, but we sometimes suffer from a lack of imagination. We tend to think only the small set of skills we all think about. Whereas if you can collaboratively come up with a whole suite of things that they're willing to try. And then the other thing, Barry, that I know comes up a lot, at least in the research end of things, is people say, don't just you need to practise your alternative skills or tools or practises when you're not crazy-triggered. It should be like a moderate trigger because you're probably going to reach for your tried and true if you're super triggered. So what do you find that way? Well, one set of skills that has been found to work is related to Joe Franklin's concept of pain offset relief, and Michael Case, a German psychiatrist, has talked similarly about this. And that is it appears-- I mentioned this before-- it appears that when you hurt the body and you stop, the physical pain is relieved. But in addition to that, the brain is tricked and emotional pain is relieved as well. And there are some skills, such as holding ice cubes, or immersing your face in a bowl of ice, or snapping a rubber band on your wrist. Notice how each one of those induces some pain, but it doesn't cause any tissue damage. And when you stop, you may get that effect of an emotional relief from that particular use of that skill. So that's one rather visceral, physical way that works for some people. So I was just going to ask, because we are going to be forward casting here. So in terms of the treatment pieces, seems like we could use personalised treatment. We still don't have very good prevention models out there, moving from averages because even I know DBT is pretty effective as it goes. But there's just a lot of play. There's not a lot of people who are always responding to the treatments we're using. So it seems like that's an area treatment, prevention are two big areas where there's still a lot of possibilities and needs for research. Do you agree? Well, I know you have thoughts about that and you've written about approaches that are especially compassionate. And I'd like you to say a little more about that, if you would. Well, I mean, I think on the-- I was very interested in the prevention front and the intervention, especially in school settings. So, it does turn out, some of the research that I was looking at a few years ago was showing one of the primary contributors to self-injury is low self-compassion. So the self-compassion inducing curricula that you can get-- and my colleague and friend Karen Bluth has done a lot of this for teens-- probably going to be helpful. So I'm hoping that we have some good research coming up with adapting that for non-suicidal self-injury and in a number of different kinds of classrooms and institutional settings. But it seems like that's an area where we really do need a good number, a good amount of research still. Yeah, one topic related to what you just said, we have to be alert to social contagion dynamics. And DBT has learned and recommended that DBT is both a group modality but also an individual therapy modality and also a coaching in crisis between sessions modality. And the group modalities have learned, you don't encourage detailed talk about self-injury in groups, because people hearing considerable details about what they use to self-injury and how much damage they did and which body part was affected, those kind of details are conducive to imitation. So groups ought to concentrate on teaching the kind of skills or tools we've been talking about here. Individual therapy is when you get into all the details about self-injury, so that there's not a possibility of it triggering other people. Same thing goes for the internet if you're channelling into sites that provide all kinds of details about self-injury specifics. Well, that's essentially you're triggering yourself if that's where you go. And you might want to choose to go elsewhere on the internet. We can't control where people go on the internet, but we can make recommendations. Totally agree with that. And then the only other area I had flagged for next steps, that if I were really doing a lot of active research right now, I'd be working in, is recovery and cessation. But I don't think of it so much as in those words. I think of it as I really-- one of my favourite studies I did with families was focused on how people grow through the process. So it's so often that we think of it as, well, recovery is kind of going back to where you were. Well, that doesn't happen. Once you've had a set of these experiences, you can't go back to where you were. But you can grow through, you can grow because of, you can grow beyond and broader. And there are, I heard, at least a third of my families, not just the people who self-injured, who had self-injury experience, but the parents or the guardians also grew independently as a result of their journey. So I'd love to us to understand how that happens. What are the key turning points? What are the mechanisms? How can we cultivate, like, all right, you're in this situation, but how do we help you grow and expand as a human while you're grappling with what you're grappling with? That's a space, I think, could use a lot more work. Your comment triggers in me another direction, which is I mentioned that a lot of the people I've worked with over the years were coming out of state hospitals or psychiatric hospitals, pretty severe impairment. Where does that impairment come from? A lot of them, it comes from profound trauma, abandonment and mistreatment and abuse. And what we discovered in working with people with complex traumas is sequential treatments may be helpful for them. Learn emotion regulation skills first, and then they can move into treatment of their traumas. And the very positive statement that can be made about traumas and PTSD is PTSD, those symptoms are learned. They're learned from mistreatment. And that means they can be unlearned. This is not some sort of biologically brain-determined predicament, PTSD. It's learned through aversive experiences can be unlearned. And it's been quite common in some of our clients. They learn the emotion regulation skills first so they can tolerate moving into the PTSD treatment. And there are evidence-based PTSD treatments such as prolonged exposure or cognitive restructuring for PTSD, which is one that I've done for a number of years. So that's a very positive, optimistic message for people with PTSD-derived self-injury. You can unlearn it and move through it. And I think that's consistent with the kind of growth you're talking about as well. Yeah. I mean, at least in my study, a third of people said they wanted to go somehow into a field that would allow them to help people like them. So it doesn't have to be-- it doesn't have to always be a really hard, horrible experience. Sometimes it gives way to something. Yeah, one thing in Massachusetts and other places is there's been a profound movement in which people with serious mental health challenges move into becoming peer support or peer counsellors. And what I say to them is your experience with mental health challenges is a credential. You can use that experience, receive some education about becoming a peer counsellor or peer specialist, and then you can help others, which does a couple of things for you. It gets you out of your own head. It gives you a meaningful direction. And you can help people at a level that I can't in terms of you having a legitimate experience that can be very helpful to share in a correct way and assist people to move out of their dilemmas. I love that. That's great. And I think with that, we're sort of wrapped up. Is there any last words that you want to share? Words of wisdom, Barry? I'd just like to thank you for inviting me to Cornell all those years ago and opening the entire field's eyes to the fact that self-injury is a pervasive problem affecting many different categories of individuals. And we still have a lot to learn, but at least we have a co-legality and a common purpose, and we support each other. I love that, Barry. And Barry, I want to thank you for all of the wisdom, humour, and deep compassion you brought to the field. I mean, really, literally for years, you did the clinical, the preclinical or the pre-conference clinical components for ISSS. And almost every year, everybody be like, what's Barry going to talk about? Because everybody attended it, because you always made us laugh. And you have such a huge, big open heart that I think has probably been extraordinarily useful and helpful for all of your clients. Well, what a pleasure to collaborate with you again. Yes, and thank you to ACAMH for inviting us both to participate here today. Bye-bye now. [MUSIC PLAYING]