Dr. David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC, covering topics of mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I am a clinical psychologist and your host. On today's show, we will be talking about a new theory of why people commit suicide with Dr. Thomas Joiner. Thomas Joiner, PhD, grew up in Georgia, went to college at Princeton, and received his PhD in clinical psychology from the University of Texas at Austin.
He is Distinguished Research Professor and a Bright-Burton Professor in the Department of Psychology at Florida State University. Dr. Joiner's work is on the psychology, neurobiology, and treatment of suicidal behavior and related conditions.
Author of over 385 peer-reviewed publications, Dr. Joiner was recently awarded the Guggenheim Fellowship and the Rockefeller Foundation's Bellagio Residency Fellowship.
He was elected fellow of the American Psychological Association and received the Young Investigator Award from the National Alliance for Research on Schizophrenia and Depression, the Schackow Award for early career achievement from the Division of Clinical Psychology of the American Psychological Association, the Schneidman Award for excellence in suicide research from the American Association of Suicidology, and the award for Distinguished Scientific Early Career Contributions from the American Psychological Association, as well as research grants from the National Institute of Mental Health and various foundations.
He is the editor of a number of publications, and he is the author of "Why People Die by Suicide" as well as a book that is currently in press, "Myths and Understandings about Suicidal Behavior." Among his many appearances, he has been on the Dr. Phil show twice. Now here is the interview.
Dr. Thomas Joiner, welcome to Wise Counsel.
Dr. Thomas Joiner: Thank you. Good to be with you.
Dr. Van Nuys: I recently discovered your work as a result of a flyer I received in the mail announcing the upcoming 42nd Annual Conference of the American Association of Suicidology - that is a mouthful - at which you will be giving a workshop.
Dr. Joiner: That is right. That is coming up in April, in San Francisco.
Dr. Van Nuys: Exactly. So, if anyone listening would like to attend, it is a three-day conference in San Francisco, and it will be held April 15 - April 18, and we will put a link to it on our website. So, if anybody wants more information, they can find it there. At any rate, as I read the blurb about you in your workshop and also found other information about you on the Internet, I quickly saw that you are a major player in this field, and I was eager to interview you.
Dr. Joiner: Well, I am happy to be with you. Looking forward to it.
Dr. Van Nuys: Right after receiving my own PhD, back in 1970, I was in charge of training volunteers for a suicide hotline in Ann Arbor, Michigan, and I seem to recall that the authority at that time was Dr. Edwin Schneidman. I blush to say that I have not kept up with the field. I am sure that quite a bit has been learned since that time.
Dr. Joiner: It is funny that you mention Dr. Schneidman. I spoke to him on the phone just a couple of days ago. He's 90 years old but still writing away and still an influential figure in suicide research. But, yeah, to answer your question, definitely there have been several exciting advances over the past couple or three decades.
Dr. Van Nuys: Let's start off with my asking how you came to be involved in the study of suicide.
Dr. Joiner: There are two sources to my professional work, one personal and one professional. The professional source was that I started out as a graduate student and then as a young professor - as a clinician and as a scientist studying major depressive disorder. I did a lot of research on that condition and on some of the psychological risk factors for it. But, as you may know, one of the main complications of that condition is suicidal ideation and behavior and, in a fair proportion of cases, death by suicide. It struck me how the worse possible complication of the condition was really getting the least amount of research attention. That kind of pushed me toward the study of suicide in particular. I'd already been doing that work when I lost my dad to suicide in 1990; that's the personal source. That certainly added a great sense of urgency to the research work.
Dr. Van Nuys: Yes. You've written a book titled, "Why People Die by Suicide." It begins with a very personal and moving account of losing your father to suicide. Do I recall correctly that this happened while you were still in graduate school?
Dr. Joiner: Right. I think I was in my third year of graduate school.
Dr. Van Nuys: Wow. Can you say a little bit about what the impact of that was on you? I just imagine how... I would think that it might have derailed a person from their graduate studies and so on to have something of that magnitude happen.
Dr. Joiner: It was very agonizing and very shocking. The loss was so profound that it is difficult to put into words. As for its impact on my interest in the field and my work as a budding psychologist, I think what you say is really true that it could have a negative effect and derail someone. But, it really had the opposite effect on me. It really created a resolve to fight the condition or the phenomenon that took my dad away.
It really has become a point of honor that the thing that took my dad away is, in a sense, going to pay. The way that I'm going to try to make it pay is to reduce and eliminate it. I feel that the only way to do that is through rigorous scientific research.
Dr. Van Nuys: Well, that's certainly making the best of a very difficult situation. Now, suicide is a large problem in this country and around the world. There are statistics that you cite in your book. I don't know if you have any of those at hand or on the top of your mind. Can you give us any of the outstanding statistics in regard to suicide?
Dr. Joiner: I think a couple that just are incredibly important is that, every year in the United States, we lose well over 30,000 people to death by suicide year in and year out. That's just in the United States alone. What that boils down to in terms of daily deaths in the US is over 80 deaths per day.
Dr. Van Nuys: Wow.
Dr. Joiner: So, every single day - today, tomorrow and the next day - we're going to lose 80 or more Americans to death by suicide. When you focus now not just on the US but on the world as a whole, we're talking about a million people who die by suicide by every year, year in and year out. It's a massive public health problem, and it's a massive international killer.
Dr. Van Nuys: OK. In your book, you advance a new theory of suicide which you say replaced a previous theory that's about 15 years old. What was that old theory?
Dr. Joiner: I think it's really a family of previous theories, a collection of them if you will. We mentioned Dr. Schneidman earlier. He had some influential theorizing about psychological pain being the key source to suicidal behavior. There were other theorists too, who were very important and who've influenced me quite a lot. I'd point to Dr. Beck in Philadelphia as someone. Dr. Beck and his team have focused on the concept of hopelessness as a very important trigger for suicidal behavior. While I think Dr. Schneidman and Dr. Beck, both, were onto something very important, I also think that they weren't specific enough. Concepts like psychological pain and hopelessness are pretty general.
Part of my work has been to get very specific about exactly what it is that people are in pain about, as I imagine we'll discuss. What I think that boils down to is a sense of being a burden on other people and also the sense of loneliness, alienation and isolation. That's my answer about getting more specific and precise about just what it is that people are in pain about or hopeless about.
The other problem that I had with previous theorists is that all of them have neglected what I think is a key precondition. It's a sense of fearlessness about pain, injury and death. If you think about it, we are self-preserving creatures. We're wired that way. We're also wired to shy away and to be afraid of things that hurt us, injure us and kill us. So, to be able to enact death by suicide, it's actually a very fearsome and daunting prospect. To be able to do it requires a certain kind of fearlessness. This fearlessness had been really pretty much completely neglected in the previous suicide literature.
Dr. Van Nuys: That sort of flies in the face of the common opinion that suicide is an act of cowardice.
Dr. Joiner: Indeed. I think that's a common misconception of what's involved in suicidal behavior. To do something as daunting and fearsome as that, it does require a kind of fearlessness. Now, by no means do I want to promote a sense of suicide as being somehow glorious, romantic or poetic. On the contrary, it's horrible and agonizing. The fact remains that to enact something this horrible and agonizing does require a kind of fearlessness. That's one of the touchstones of the new theory of suicidal behavior that I've developed.
Dr. Van Nuys: Take us through that new theory a bit more, if you will. Maybe you can tell us how it emerged from your own clinical work or research and say a little bit more about each of the main pillars of the theory.
Dr. Joiner: Sure. There are three main pillars. I've already prefaced each of the three. Let me just name them, and then I'll go into each of them specifically.
Dr. Van Nuys: Great.
Dr. Joiner: The three are perceived burdensomeness. The second one is isolation, loneliness, alienation and that kind of thing. The third pillar is that sense of fearlessness that I was referring to. And the way the theory is put together, the idea is if somebody feels like they are a burden on the people they love, in other words, they have it in their heads, the mental calculation, "My death will be worth more than my life to people that I care about," if they think that's true, even though it's rarely true, if they believe it to be true, the idea that, that's an important precursor to the desire for death. But, there is another piece of that puzzle and it's the loneliness, the alienation.
Theory claims that if people feel the sense of burdensomeness together with the sense of alienation, if they feel that long enough and severely enough, they will develop a desire for death. This desire for death is actually a fairly common phenomenon. It certainly is common along in patients in psychiatry where a lot of patients are maybe depressive disorder or bipolar disorder. Very common aspect of those conditions is they have ideas about suicide, desires for suicide and yet a striking fact is that luckily, relatively few of the people who have ideas about suicide, attempt suicide much less die by suicide.
And that's where the fearlessness piece comes in the third pillar. The idea is that of all the people who desire suicide it's only a very small portion who have developed the wherewithal to enact suicide, the sense of fearlessness about injury, pain and death. You can think of the theory as a perfect storm kind of theory where three things have to come together simultaneously. Those three things again are perceived burdensomeness, a sense of isolation and this characteristic of fearlessness.
Dr. Van Nuys: OK, you have a chapter on what we know and what we don't know about why people commit suicide. So, let's look at those two pieces. What is it that we know?
Dr. Joiner: Well, there are a lot of facts about it. There are facts, for instance, that we were talking about. Although in the US, eighty people die everyday, that sounds like a lot and it indeed is a lot, it's eighty too many in my point of view. That actually is a low figure when you compare it to some other causes of death like heart disease, for instance. We lose 2000, over 2000 Americans every day to heart disease. And so suicide is a relatively rare form of death and so that is something we know to be a fact. We know that gender is associated with suicide in very interesting ways, namely that men are far more likely to die by suicide than women whereas women are more likely to attempt suicide but survive. We know there is an association with ethnicity. In the US, Caucasian people are far more at risk than all other ethnicities except for Native American people who have similarly high risk rates as Caucasian people. And there are several other facts like that, that have been established. What my work is partly trying to do is develop a new explanation of suicidal behavior that can shed some new light on these old facts.
Dr Van Nuys: What is it that we don't know? Where are the gapping holes in our knowledge?
Dr. Joiner: The Holy Grail so to speak is 100 percent prediction, risk assessment protocol allow that will allow 100 percent prediction. We are nowhere near that. Similarly, we are no where near treatments and prevention programs that are 100 percent protective so there are some crucial things where our knowledge base is coming up short and where we need to do a lot more to save lives.
Dr. Van Nuys: What about the role of genetics? Do those play a role?
Dr. Joiner: Absolutely, there is no question that there's a genetic component. The best estimates of how much of suicidal behavior is genetic comes down along the lines of 35 percent, 40 percent, somewhere in that ballpark, which means that 60 percent of how things turn out has nothing to do with genetics. Like a lot of complex human behavior, there is a genetic piece and there's a non-genetic piece, with suicides a substantial genetic piece. It shouldn't be overblown. It's about 35 percent, maybe, 40 percent of outcomes.
Dr. Van Nuys: I know that you're also interested in the role of the brain. We have been discovering so much about the brain with the neuroimaging tools that we have available today. What can you say about the role of neurobiology?
Dr. Joiner: Well, it's a fascinating fact for a behavior that is as complex as suicidal behavior, you would kind of imagine that all sorts of brain regions and all sorts of kinds of neurochemicals and other neurobiological factors are implicated, but actually the best research to date really pins down most of the action at the brain level in the serotonin system. Since serotonin is a neurotransmitter chemical, it is very important for the regulation of mood and sleep and appetite. We were just talking about the genes that are involved or the genetics that are involved. We haven't really located specific genes that are candidates for risk factors, but we have honed in on a couple or a few. The most promising of all of them are genes that code for various aspects of the serotonin system. Neurobiologically, the research is on the trail of genes and other factors that influence the serotonin system.
Dr. Van Nuys: Well, that sounds exciting. What about the role of mental disorders, for example, depression, bipolar, schizophrenia and so on?
Dr. Joiner: I think two points are crucial. The first is that there is a clear role, an absolutely essential role, for mental disorders and suicidal behavior. There is a wide consensus in the field that at least 90 percent of suicide decedents are experiencing a mental disorder at the time of death. You mentioned the main ones - major depressive disorder, bipolar disorder, schizophrenia. Another big two are borderline personality disorder and anorexic nervosa. My view is it's actually more like 100 percent of suicide decedents are experiencing some form of a mental disorder at the time of their death so that's a crucial fact. But, the other crucial fact is that if you look at all the people who have mental disorders, we can just focus in on one, major depressive disorder. Of all the people that have that condition, it is crucial to remember that only about eight percent, seven percent, something like that will end up dying from the condition through suicide.
So, the conditions are extremely important, but by themselves they are not enough to explain suicidal behavior because most people who have the illness don't end up dying from it via suicide.
Dr. Van Nuys: Well, what about the role of age? I'm kind of imagining a U-shaped curve with suicide being higher among teens, say, and the aged. I don't know if that is accurate.
Dr. Joiner: No, it's really not. It's more of a linear line upwards. The older you get, the more at risk you are. It's interesting about the teens. There's definitely been a noticeable increase in the rate of suicide among youth. In fact, some of the best data suggests that over the last 25 or 30 years the rate has nearly doubled among young people. But, even with that near doubling, the rates are not even close to what they are in people who are 50, 60, 70 and so forth. It's pretty much a linear trend up the age range.
Dr. Van Nuys: Yeah. When you were talking about one of the main pillars of your theory was the isolation burdensomeness, all of that, that sort of brought to mind the older population.
Dr. Joiner: Yeah, I think that's one of the facts, one of the empirical facts that we were talking about earlier where we know this to be true. It's one way or one fact that I think my theory explains in a way is arguably more persuasive than past theories. Certainly, the fearlessness component fits with the age finding, the idea being that it's only with experience, practice and age that people can get used to a dangerous thing, things that will hurt them or kill them. And certainly age is going to be associated with that kind of experience and previous practice.
Dr. Van Nuys: So, would there be a correlation then between people who are sort of thrill seekers who have done a lot of potentially life threatening things like maybe sky diving or other kinds of activities like that?
Dr. Joiner: Absolutely. It's kind of complicated how it works. Certainly, those kinds of behaviors will instill the fearlessness component I am talking about, but it's really important to remember that that's only one piece of the puzzle, and you've got to have the other two pieces as well. So, yes, those kinds of behaviors do increase one aspect of the model, but it might not increase the other two and thus may not increase the outcome of death by suicide. You see this in a lot of different populations. Right now, the very worrisome and timely topic is death by suicide in the military. Certainly, those men and women in combat have plenty of opportunity to witness or experience themselves things that have the potential to get them used to pain, injury and death. That's one possible factor that's potentially an explanation for why we're seeing a real rash of suicides in the military.
You see it in physicians too. Physicians have among the highest rates of suicides among the professions, and I think that's largely because day in and day out their work gets them used to injury and pain and violence and, indeed, death. If the physician develops the desire for suicide, he or she is uniquely equipped to enact it.
Dr. Van Nuys: Yes. Well, what are the signs that someone is at risk to commit suicide?
Dr. Joiner: This is just a crucial question because it's so important for public health. It's a simple message, but it's one that's very often overlooked. The clear signs are the most obvious ones, things like, people are saying that they intend to kill themselves. People are writing notes about their intentions to kill themselves. People are giving away prized possessions in a kind of inexplicable fashion. These are extremely obvious things, but you'd be surprised or, perhaps you wouldn't. Anyway, they are overlooked all the time. In terms of warning signs, those are really crucial ones to pay attention to.
Some other important ones are things like a very dramatic change in behavior or mood for the worse and signs having to do with agitated, sleepless kinds of states of mind. When people are having bad insomnia, combined with a kind of agitation where they can't get comfortable in their own skin, that's an important danger sign as well.
Dr. Van Nuys: Now, you suggested that we don't have any sorts of 100 percent therapeutic interventions. But, what sorts of interventions do you recommend?
Dr. Joiner: I think one of the simpler ways to come at the question is to go back to our discussion about mental disorders. They certainly do seem to spur a vast majority, if not all, of suicidal behavior. Therefore, it stands to reason that if those underlying conditions are aggressively treated that this should - one would think, one would hope - reduce the outcome of suicide. So, very good, modern scientifically-supported treatments for conditions like major depressive disorder, bipolar disorder and schizophrenia... In most cases, that will involve medications - especially for schizophrenia and bipolar disorder - combined with modern, very here-and-now kinds of psychotherapy. Usually, those will fall under the umbrella of cognitive behavioral psychotherapy. That is kind of the leading treatment package for virtually every major mental disorder. It's a combination of cognitive behavioral therapy with an appropriate medicine.
Dr. Van Nuys: What advice do you have for family or friends who may be dealing with someone who's feeling suicidal?
Dr. Joiner: The warning signs is a great place to start. Those are the things to look for and to watch out for. Another piece of advice is to patiently, but very persistently, counsel treatment and encourage treatment - go to one's doctor to talk about a medicine, seeing a psychologist for therapy, et cetera. Another very important resource is the National Suicide Prevention Lifeline. This is a project that was funded by the federal government. The toll-free number associated with it is 1-800-273-TALK. That's 273 T-A-L-K. The great thing about this project is that it links together about 150 crisis centers across the country, all of which are adhering to the standards developed by the project. Wherever you call in the US, 1-800-273-TALK will link you with a trained crisis counselor.
Somebody who's in crisis themselves certainly can call that number, so can family and friends call that number for advice and also for tips about how and where to access treatment.
Dr. Van Nuys: That's a great resource to be aware of. I'll make sure that we put that in our notes as well. Closely related to my last question, how can friends and relatives support someone who has already lost someone to suicide? I know in your book, in that chapter where you talk about your father's suicide, you recount stories of how some people had very helpful things to say and other people didn't. So, what counsel would you offer people in that regard?
Dr. Joiner: Basically, it boils down to just to acting right. If somebody that you know has lost a family member all of a sudden, what's acting right? Well, it means going to the funeral. It means providing support. It means checking in on them, just as you would for anyone that has lost a loved one suddenly, whether it is a heart attack or stroke or an accident or in this case, death by suicide. I think that trips a lot of people off. I know it did in the aftermath of my dad's death. That where people just somehow get it in their head that this is different and scary and taboo territory and so they back off and they ignore the family and so forth. Virtually every family member who has been through this will tell you a similar story.
And that is exactly the opposite of what's needed. What's needed is just acting right, support, condolences, checking in, just like if it were any other form of death. I should also say as you pointed out that there are several people, friends and others who did that for me in my family, but there certainly were others who failed in that regard.
Dr. Van Nuys: Yeah, I think often people feel a kind of paralysis of fearing that they are going to say the wrong thing and so unfortunately they say nothing and withdraw from the situation.
Dr. Joiner: Yeah, I think you probably put your finger on an important part of it. And I would just counsel people to overcome that fear and to remember this. It is kind of hard to say the wrong thing if all you are saying is how sorry you are and how much you want to help out.
Dr. Van Nuys: Yeah, somewhere I saw you are working on a book about myths and misconceptions about suicide. Now are they any major misconceptions that we haven't covered here?
Dr. Joiner: Well, we talked about a major one that it is mostly the province of cowards and how that's wrong because it actually requires a kind of fearlessness. We have a few others that we probably haven't touched on too much. The book, it is coming out in about a year. It covers around 25 or 30 individual myths or misconceptions. I guess I will just pick a couple out more or less randomly. One is about suicide as anger turned towards the self.
Dr. Van Nuys: Oh yes, that's kind of like a psychoanalytic notion.
Dr. Joiner: Yeah, definitely and a related notion is that it is all about revenge. And my view on that is that's not quite right. Occasionally, there are deaths by suicide that tend to have that character but if you harkens back to the three pillars of my theory especially the one about burdensomeness, if it's right that burdensomeness is the main cause of suicidal behavior, that's really the opposite of trying to get revenge or anger. What the suicide decedent is thinking - now this is a mistaken thought, but that's what they are thinking - is that they are actually doing people a favor. They think that by removing themselves, they are helping everybody out. Now, they are tragically wrong about that but the catch is that they don't know that they are wrong about that. They think it to be true and it spurs their behavior. So, trying to help people out is actually the opposite of trying to get revenge on them.
So, I think that one is an important myth. There are a few others, one having to do with treatment. I am really concerned about the FDA and the media's treatment of antidepressive medicines, things like Prozac, Paxil, Lexapro, etc.
The data are so clear that they are helpful treatments for conditions like manic depressive disorder. There are occasional side effects where people do get ideas about suicide from the medicines, but in my opinion this has been terribly overblown to the point where a lot of physicians, especially primary care physicians, are scared off of prescribing them and I am just very concerned that can have a backfiring effect, where suicides are going to increase because people are not getting the right treatments and enough of the right treatments for the underlying conditions for suicidal behavior.
Dr. Van Nuys: There are a couple of specific issues I would like to ask you about. We've mentioned the upcoming conference of the American Association of Suicidology where you are going to be giving a workshop in San Francisco. You're probably aware of the long standing debate, or maybe not, since you don't live in this area. In regard to putting a barrier on the Golden Gate Bridge to stop people from committing suicide. I'm not sure if the issue has been settled yet or not but I believe there are issues of costs and aesthetics versus trying to save lives.
Some people say if a person has decided to commit suicide they'll find a way regardless. Do you have an opinion regarding a suicide barrier for the Golden Gate Bridge?
Dr. Joiner: Yeah, absolutely. This hits on another of the myths that I cover in that book. The myth being that if somebody is prevented at one location they'll just go to another location. Or if they have one means taken away from them, they'll just access some other kinds of means. In this case, someone is prevented by a barrier at a bridge, they'll just go to another bridge or they'll just go somewhere else and use another means. That's a myth. The evidence could not be clearer that things like bridge barriers work. When they are put up they save lives and people. You do not see an increase in deaths by jumping from other bridges or from accessing other kinds of means.
I could not be more in favor of bridge barriers because they have been shown in my view definitively to save lives. And I think it is pretty unconscionable that one was not put up at the Golden Gate, but that's changing. That is going to happen. The issue, as you pointed out, one is money and aesthetics.
For someone like me to hear that money and aesthetics are more important than saving lives it's a moral outrage and I'm glad that the Bridge Commission and others have come to their senses about that.
Dr. Van Nuys: OK. Good. I'm glad I thought to ask you about that. Now, what about the issue of assisted suicide for the terminally ill. Is this an issue that you have studied?
Dr. Joiner: A little bit. I'm interested in all phenomena that have suicidal elements. Assisted suicide would be one. Suicide terrorism would be another one. These are tricky things to explain theoretically and most previous theories have just said at the beginning, I don't know about all that. I don't know about suicide terrorism. I don't know about assisted suicide. What I've tried to do is take a different tact and say, yes, there may be conventional suicides where we should be focusing most of our attention. But, there are also suicides that on the periphery of the conventional definition that probably also needs attention.
I've tried to explain some of these phenomena with the three pillars of my theory. With regard to assisted suicide, it's an interesting fact of all, if you take a large group of people who are terminally ill and then among that group, it's first of all crucial to point out that only about a third of them desire death. Even if you take a group that is all equally ill, all equally in pain, only about a third of them will desire death. Interestingly that third is characterized by a desire to make other people better off, very akin to my theoretical concept of burdensomeness.
So, I think that it's a concept that can be fit into the theoretical framework. Having said that, though, the law in Oregon has it worked out pretty well. They have structured it so carefully. They have just made it very safe, in the sense of not letting people who are primarily going through a mental disorder access this procedure. So, I will say that I have been impressed with how the law has been developed and enacted in Oregon.
Dr. Van Nuys: OK. Well, are there any other thoughts that you would like to share with our listeners as we wrap up?
Dr. Joiner: I would just remind everyone of a couple points. One is how treatable these conditions are that underlie suicidal behavior. It can take a lot of persistence and patience, but they are treatable. Accessing good psychotherapy which means modern and scientifically effective treatments combined with medicines or just really, that's so crucial. Another thing I would say is to have compassion for people who attempt suicide, people who die by suicide, and their family members. They need compassion. They deserve it. And if we take a compassionate view and a scientific view and put those two things together, my hope is that we'll make progress in the coming years on reducing death from this massive international killer.
Dr. Van Nuys: Wonderful. Well, Dr. Thomas Joiner, you have been very generous with your time and information. I want to thank you so much for being my guest today on Wise Counsel.
Dr. Joiner: You are most welcome. I appreciate the opportunity. [music]
Dr. Van Nuys: I hope you found this interview with Dr. Thomas Joiner as interesting as I did. I believe him to be one of the foremost voices in suicidology today. If you are a professional looking to earn continuing education units, you might want to consider attending the American Association of Suicidology Conference in San Francisco.
Once again, the dates are April 15th through the 18th, 2009. you can find complete program details on their website at www.suicidology.org. And you might also want to make note of that national suicide life line number. Once again, that's 1-800-273-TALK.
You've been listening to Wise Counsel, a podcast interview series sponsored by CenterSite, LLC.
If you like Wise Counsel, you might also like Shrink Rap Radio, my other interview podcast series which is available online at www.shrinkrapradio.com and rap is spelled r-a-p. Until next time, this is Dr. David Van Nuys and you've been listening to Wise Counsel.