Alcohol-Related Liver Disease: treatment and recovery with Lesley & Dr Ashwin Dhanda

In this episode we discuss alcohol-related liver disease (ARLD), what it is, its treatment, and hear Lesley's experience as a survivor of ARLD and transplant. Lesley was a patient of Dr Ashwin Dhanda, a liver specialist, and both provide their insights into the condition and how society should do more to raise awareness of and prevent alcohol-related harm and ARLD.

Ashwin Dhanda is Professor of Liver Medicine at the University of Plymouth and a liver specialist at University Hospitals Plymouth NHS Trust. He leads a programme of research around stigma in alcohol-related liver disease including identifying causes of stigma and how it affects people and designing interventions to tackle it.

Lesley was diagnosed with ARLD in December 2019, which led to a liver transplant in December 2019. She is part of a liver support group supporting other patients and working as a patient representative with Ashwin on a research project around stigma in alcohol related liver disease and helping the research team design interventions to tackle it from a patient/peer perspective.

Transcript

James Morris: [00:00:00] thanks so much for joining me Leslie and Ashwin if we start off could you just briefly tell me a bit about yourselves and perhaps if we start with you Leslie

Lesley: so in December 2018 I was admitted to hospital with um alcohol related liver disease Um first admission had never spoken to anybody about it Um convinced myself nothing major was happening Um anyway I ended up Being severely ill um pretty much towards end of life And um yeah and and so although I'd kinda known I was ill um I didn't want the shame and embarrassment to say that it was alcohol related Um so that's how I surfaced [00:01:00] Um but that was my first presentation I you know had nothing indicating I did have indicators but I told myself it was something completely different

 James Morris: Thanks Leslie And yeah it'd be great to hear a bit more about Your experience and and some of the really important aspects of that but yeah Ashwin can you just briefly introduce yourself and uh tell us what you do

Ashwin: Thanks James Uh so I'm a clinical academic And so I have half my time looking after patients who have various different liver disease And my other half I spend at the university researching challenges that people face who have alcohol related liver disease And recently my program of research has focused on stigma around alcohol and around liver disease and trying to understand more about the challenges people face and what barriers and facilitators we we can use to try and tackle stigma or improve patient outcomes

 James Morris: Thanks so much and yeah it's obviously so important given [00:02:00] that we know how high levels of stigma towards alcohol problems are um you know persistently high and and a real barrier to treatment care and early intervention But um perhaps ashwin could we start off By just talking a bit about alcohol related liver disease can you give us a brief overview of how alcohol and particular heavy drinking does affect the liver and what that can lead to

Ashwin: So alcohol has a direct toxic effect on the liver it causes direct damage to the liver cells as well as causing fat deposition in the liver over a period of time fat can cause damage and scarring in the liver and eventually it can lead to cirrhosis of the liver Uh now the amount of of damage is directly related to the amount of alcohol that is consumed and the higher the amount that the more likely that that person will end up with some form of liver disease [00:03:00] alcohol related liver is is a huge spectrum that first stage I mentioned fatty liver is experienced by about nine out of 10 people who drink heavy amounts of alcohol Um which which means about 50 units a week for for men 35 units a week for women so most of those people will have fatty liver Um then smaller proportions would have uh fibrosis which is early scar formation which is still reversible and then a smaller fraction still of maybe about five or 10 would have scarring of the liver which is cirrhosis and that is considered irreversible

 James Morris: And um you said you know there's that direct relationship between consumption and the risk of of liver disease or cirrhosis but it's also um a kind of exponential relationship isn't it So any reductions are are kind of good But then there's a stage as you said where Abstinence is absolutely necessary And we'll talk more to Leslie a [00:04:00] bit in a minute But um it's that exponential curve I think isn't it

Ashwin: yeah I think you're right Um The other thing to emphasize is that in the earlier stage of of liver disease It is a reversible condition And so cutting back the amount of alcohol consumed can let the liver repair Um and I've seen patients who've had severe liver disease that have come into hospital bright yellow with jaundice um and liver failure And then after a period of of know six months of not drinking their liver has completely regenerated Um but yes you are you're completely correct that the more that people drink it's an exponential risk and the other thing to note is that you know people don't just have alcohol as a risk factor in isolation so it's if, people have other other conditions like diabetes or obesity it's not simply an Additive risk of the risk of diabetes plus the risk of alcohol use It is multiplied risk of alcohol plus whatever [00:05:00] other risk factor so it is very important to address the whole problem that the individual might face not just the alcohol use

James Morris: Yes Yeah that's really important And yeah and I guess the other thing as well is that liver disease doesn't necessarily have signs or symptoms You in early or at least mid stages you could have liver cirrhosis and you wouldn't necessarily know So I guess that's another important point isn't it That it's uh hidden until kind of often later stages

 Ashwin: Yeah absolutely It is a silent disease and About half of people who who are diagnosed with liver disease are not diagnosed until they've reached the final stage of of having to come into hospital because their liver has started to fail Um so it's really important to recognize the the risks that alcohol has and to identify and screen patients uh to look for liver health before it turns into a a bigger problem that's more difficult to to fix

James Morris: Yeah So I think yeah maybe we'll talk more about the liver screening possibilities later [00:06:00] but So so Leslie Yeah Could you tell us a bit more about your experience So yeah you said that that when you were admitted and yeah it was all a bit of a surprise and so on But yeah Can you tell us a bit more about your diagnosis and your treatment and what followed from there 

Lesley: So yeah I mean I I um I don't actually think I realized when I was admitted how poorly I actually was Um And it was sort of friends that sort of dragged me more or less to accident emergency and and dumped me Um and you know I I was sort of um I had what they call Ascites which meant my liver wasn't processing getting rid of fluids So I was absolutely swollen massive So the first thing that sort of happened was an ascetic drain and the drain dating liters And I kind of thought oh they've done that I'm gonna be better and I [00:07:00] can kind of go home But it all started to come back so I ended up Sort of spending sort of four weeks in hospital Um you know I was really well treated I was I was given an you know endoscopies everything everybody was was pretty good you know um but I was judging myself I was you know I was still kind of a bit in denial so I got Out hospital discharged Um but very quickly my liver wasn't getting better So my week often meant spending a day in the planned intervention unit to have this fluid drained Um and then one of the senior nurses came and said I think we need to talk to one of the consultants Um and they came down and said Your liver's not getting better you need a liver transplant And I was absolutely absolutely [00:08:00] not You know Absolutely not I I can get better So even then I was trying to heal myself but it was a it was a process of accepting you know this was this was gonna save my life basically So you know a couple of months staying the line Um I was very malnourished Um and you know when they'd first mentioned it I there's absolutely no way that I've I could barely walk Um how was I gonna have a liver transplant So there's a whole combination of different things that I had to do for myself and everybody's different Um I wasn't offered much in the way of support from support groups I had one or two with a local group but it kinda wasn't for me Um and then once I'd kind of accepted it friends were amazing Hospital team were amazing I had the assessment I went up to Kings in London and I was accepted [00:09:00] And so almost a year later um I had my liver transplant Thank you to an amazing donor in the family um and a an amazing team looking after me So and yeah here I'm

James Morris: Amazing Yeah and so yeah it's it's really interesting how you talked about that kind of process of you know like accepting what was happening and that your liver was failing and you needed a transplant could could you maybe say a bit more about how much of that was maybe um maybe or anxiety understandable about the kind of um health implications of that and how much of that was maybe about the stigma or fear of stigma around um you know it being caused by your alcohol use

Lesley: Yeah I think um It's really difficult to admit to yourself that that's a problem Um because you know you you just [00:10:00] people just talk about alcoholics you know what does an alcoholic look like Um you know is it the person that's sleeping that's rough that's homeless Um and even now you know people will look at me and and they wouldn't Uh they wouldn't see that alcohol was my problem Um you know they don't automatically say oh you know so you know oh so you have you know alcohol use disorder or alcohol dependency I'm just not what they perceive you know so they have people have very fixed ideas I think Um and I think I think for me I I haven't really had too many problems with with health professionals Um as I say I've I've had a great supportive team but um you know I know other people that have even down to GPS and and and Junior resident doctors Um but I think yeah I think coming to terms with it [00:11:00] myself was was was one of the big things for me really Um and just um acknowledging it and you know Once you can kinda do that but you you you know it is everywhere People just will joke about alcoholics all the time and so I'm always sort of on guard a bit about it So you know and then it's just it's just changing that perception and and giving people the support they need

James Morris: Yeah I think that's such an important point You know the the stereotypes around what a kind of problem drinker is Yeah They are so rooted in these kind of ideas of you know park bench and needing a drink in the morning that that really does really obscure the wide range of heavy drinking that exists in society and the impact that has on liver disease So yeah I think that's so powerful that you can really highlight that you experienced um liver failure as a result, [00:12:00] result of your drinking but you don't kind of reinforce those stereotypes Um so it's it's it's difficult isn't it to sort of challenge that stigma and not reinforce Yeah We don't want to reinforce negative stereotypes but really highlight how um this cultural normalization of alcohol really does obscure the kind of reality of the costs and consequences to not just health but social costs as well Um so yeah maybe we'll come back to a bit more about, , how you got to that, point and your recovery after But Ashwin do you want to say anything about The interface of treatment and stigma and what kind of happens when people are diagnosed with liver disease

Ashwin: Yeah so I I think you know there are there are different types of stigma Um so you mentioned about you know public perceptions and stereotypes You know that drives Stigma and and Leslie briefly mentioned about experiences that other patients have had from healthcare professionals So you know even those that are trained to deliver and and improved quality of life and [00:13:00] treat patients They also have you know stigmatizing approaches or behavior Um and I think that drives the the self-stigma of of the individual it leads to um to to feeling worthlessness It it drives secret behavior hiding alcohol use from their family Um and what happens is that it, results in a lack of engagement with clinical services or seeking help from healthcare professionals So it does result in delayed presentation And as we said before you know half of the patients who are diagnosed with alcohol related liver disease have already picked up very late So that's part of the problem Um but those that that are diagnosed Um such as as Leslie you know that first time they have that interaction with the healthcare professionals really key And there are there are multiple opportunities for interventions and small changes [00:14:00] can result in in quite big effects Um so even a short what's called a brief intervention which is a structured interview with a with a patient providing some reflective discussion and trying to to help people understand what their problem is and how they could deal with that You know that brief intervention has significant benefits and can reduce alcohol use in in people if it's used the right time Um and one of the times that that is Really useful is when patients have come in in a crisis to hospital when they have referred to sometimes as a teachable moment So you know they've they've come in in a crisis and they they're looking for help Their mind is opened They understand that there's they've had a significant problem with alcohol They might be willing to hear about ways of of helping or accepting treatment at that stage So I think behavioral [00:15:00] Interventions brief interventions those are really important for anyone who has alcohol related liver disease Um and then it's later on where those perhaps haven't worked or the liver has continued to to fail That we need to think about other treatments Um and and liver transplants is the is the final treatment that we can offer to patients whose liver has completely failed Um but that does require the patient to go through a number of hoops including achieving long-term abstinence to show they they are committed to the change in lifestyle that that they need to to maintain the health of their new liver if they get one from a transplant program

James Morris: and what about at what point does abstinence become necessary or certainly advised in heavy drinking Is it is there a way of kind of saying a kind of cutoff almost where you can say well it's no longer about drinking reductions and a sort of brief intervention but now about abstinence and maybe [00:16:00] some kind of structured alcohol support around kind of addressing dependence and so on

Ashwin: Uh yes I think when a patient gets to the stage of cirrhosis which is irreversible scar formation of the liver from that point onwards the the best that that patient can do is to achieve long-term abstinence Um and so that's the message from healthcare professionals You know it should be acknowledged that that's not possible for all patients Um and in some people we have to have we have to take a harm reduction approach And so you know the message is less is more the less alcohol that can be consumed the better it is for their liver but that's only you know the second best option compared to abstinence in people who who will have earlier stages of of liver disease like fibrosis or fatty liver they should be counseled that uh that reducing alcohol is important and abstinence is again the best option for them because they [00:17:00] already have some liver damage They're already on that pathway Um But there is a bit of fluidity there and and some negotiation and discussion Um it's not completely black and white but I would say that those with cirrhosis, it is much more didactic that we would we want patients to be abstinent

James Morris: Yes Yeah And of course it's only pragmatic to meet people where they're at and you know for that process of coming to terms with maybe lifelong abstinence is understandably maybe scary or difficult to accept in that moment for many people when their whole kind of lives and social networks have been built around drinking and alcohol use Um and just quickly maybe how how would cirrhosis be diagnosed you know there's degrees of cirrhosis but how is it actually tested in practice

Ashwin: Uh yeah So first is that blood tests are not very helpful They don't always reveal the extent of liver damage and can be completely normal even in [00:18:00] patients who've got cirrhosis So we need better more sophisticated tests and ultrasound um which is a jelly scan of the tummy uh can detect cirrhosis in people who've already got quite established and advanced forms So again it's not perfect It does pick up that end that extreme end of the spectrum so what we like to use Is a fibrosis test And there's one that we we use in this country which is called a fibro scan Um which measures the stiffness of the liver Again it's a a type of ultrasound wave that that is uh pressed on the on the tummy and it gives a reading and the higher that reading is the more stiff the liver is And that Correlates with how damaged the liver is So very high readings mean that that person has cirrhosis Um so that's a a non-invasive way which which means you know we're not sticking needles in or taking a sample of the liver to make a diagnosis Um so it's a non-invasive test uh is very accurate It it's [00:19:00] painless So it that has a lot of advantages The challenge is that most places in this in the country and and probably globally it's limited access It's um it's held by hepatologists the liver specialists Um and so the person needs to be referred to us Um and but there are some new pilots going on that are trying to bring that more into the community where liver disease is more prevalent So where there's more of it and so we are seeing um areas where where there are community liver scans being conducted And that's part of an NHS England program and so far more than a hundred thousand scans have been conducted in that way Going to GP practices alcohol services areas um of social deprivation where there is there are more people who have liver disease and it does pick up cirrhosis in around [00:20:00] one in 10 to 12 patients who undergo that scan Um so that that's a newer way to screen for liver disease before the symptoms arise

James Morris: So you mean one in 12 people around that marker being successfully detected and that's the sort of rough number of people, that are. With liver cirrhosis, after completing the scan? 

Ashwin: out of those a hundred thousand patients those those people have most of them would have some sort of risk factor of a liver disease Not just alcohol use but they might have obesity diabetes exposure to viruses like hepatitis C So out of those a hundred thousand people um around or 8,000 of them Have been diagnosed with the fibro scan confirming that in the range of cirrhosis

James Morris: Yeah that's really it's really important And yeah I was aware that the blood tests are an unreliable marker and yeah that lot of people might be getting false reassurance maybe from a a blood test that [00:21:00] didn't identify anything when they may actually have liver damage or cirrhosis Um Leslie would you tell us a bit more about your journey maybe what your experience was What led you to get to that stage Or if you prefer more about kind of your recovery journey

Lesley: so it sort of started with um you know like a habit that you would go home and you'd have a glass of wine You know you'd had a rough day at work you'd have a glass of wine or I kind of used it Uh to sort of combat stress um instead of dealing with problems I would sort of almost think I could sort of do you know what I'll just have another couple of glasses of wine and the problem will go away And it's only wine It's nothing serious I'm not drinking a bottle of vodka You know it's only wine It's only Prosecco You know I'm not Having a bottle of gin I'm I'm not drinking spirits Um and then the habit sort of becomes a dependency and [00:22:00] you know you would Go out and I would I would you know I would go out and I would always be thinking about not driving because if I drove I couldn't have a glass of wine And it kinda just it became the norm Um I worked I got a job where I worked away from home and we worked hard and we played hard It was quite stressful You know and I I had I had one of the nicest colleagues and she would always say well let's just have another but she meant another bottle not another glass And you're in that culture and it kind of it's acceptable and it's great and you know it's not really seen as a problem You can function you can do your work you can you know Do whatever You can live your life and you can function so you know what's the problem kind of thing Um and then it sort of keeps up you know um and then yeah I you know sort [00:23:00] of masked it and you know I sort of had some problems in life and then Made a complete change moved to Plymouth Um so it was kind of in the background It was always there Um and I was always like but I can stop when I want You know you know I'm I'm I'm a fun person and I can stop when I want And then you actually can't And then it starts to take over your life a lot more And then you know I became unwell and I was still trying to convince myself it wasn't alcohol Um So yeah and I think the other thing is You know that that's a tell in yourself You can stop Um and then covering it up because you don't want people to sort of think you've got a problem Um you know because there's the stigma associated with it And and then I think it gets to the point you know when I was admitted and [00:24:00] when I was really really poorly um before my friends had dragged me in it was kind of well I I don't deserve to be cur not cured I don't deserve it You know they're gonna take one look at me and go you've caused this you brought this on yourself You don't deserve it You know so the there was also this that I wasn't deserving when there was other people Um you know people who have cancer that need cured and things I didn't deserve it You know I didn't see it as an illness um which was quite a big thing Um so yeah there was that and it was just I I because I didn't realize how bad it was Like I'd said I just thought well I'm gonna have this and I'll get better You know I mean when you actually look at I said they drained off 18 liters I mean you imagine 18 liter bottles of Coca-Cola and I was carrying that around with me You know it it just seems crazy now [00:25:00] Um and once the ascites starts um I dunno I mean Ashwin probably can see but it's it's kind of your end stage It's not going away really Um you know it's it's it's managing it and and trying to you know see how how best you can be supported Um and I'm very aware that not everybody makes it to liver transplant Um and that itself brings its own issues I mean don't get me wrong I'm absolutely grateful to be here but you are living with a different set of issues afterwards So and the fact that you know again the stigma about it not the transplant but the reason that you had the transplant

James Morris: Yeah for that reason you know I'm so grateful for you coming on and sharing your story and it's yeah really I think powerful the way you described that sort of normalization of drinking as embedded [00:26:00] within our kind of everyday lives uh within our work and our socializing and our de-stressing You know that's such a a common reason that heavy drinkers often cite in the qual research you know oh it's a it's a de-stress or I've I've kind of earned it So yeah I think that kind of explanation of how it was so normalized and embedded within the everyday lives and that's how it can uh come to be a problem as it just sort of builds up and develops over time and then yeah as well the stigma that you mentioned that self-stigma So yeah Ashwin mentioned the public stigma how the public hold these negative stereotypes and yeah if you you know have an alcohol problem it's hard in some ways not to internalize those and feel some degree of guilt or shame or blame or whatever So yeah really powerful that you can yeah Explain what that was like Um And and what about the process uh after the transplant You said you know it's not straightforward and Yeah Um you're kind of well and and functioning now but there's [00:27:00] still managing it

Lesley: Yeah 

You know you you um you're grateful for the transplant Some people suffer rejection Um you know you you you take anti-rejection drugs for life Your regular appointments with consultants at the hospital You know the one of my friends said to me um it's like they be a second family because you will always need the support of the the hospital the hepatology team you know it's it's like a second family almost And it it's true You know we we are constantly um You know having checks and different things done and I you know I'm grateful but you're you're you're not I mean you're you're living a great life or most people are but you know you you are you have to be a lot more careful about things You end up having to have steroids which you know again have their own sort of knock on effect Um and and and I think for a lot of people coming to terms [00:28:00] with the fact that Most of the time somebody's died for you to live So you you have to live with not the trauma but you have to be able to deal with that And I I'm very lucky that I wrote to my donor's family and they write back Um and they're just so grateful that I am well Um you know so but they don't know that I got my transplant because of alcohol related liver disease and I don't know how they would feel about that So I still have worry attached um not worry but a bit of shame attached that you know would they see me as somebody who was sick or would they see me as somebody who didn't deserve a transplant Somebody else should have got the liver Um so you you're kind of dealing with a lot of the emotional side which To be honest I don't [00:29:00] think there's a lot of support for it unless you kind of do it yourself Um yeah

James Morris: Yeah it's interesting , never thought about that but yeah I can understand that And I think again it relates to the public stigma It's it would sort of almost be hard not to assume that they're sort of wondering That in some ways but um That must be a Yeah Some understandable thing to kind of wrestle with but I'm I'm hopeful that they they wouldn't be kind of judging you in the way that the sort of public stigma suggests that many people might Um ashwin do you wanna reflect on on anything we've discussed there or say anything in particular about the treatment or prevention of alcohol related liver disease

Ashwin: Uh I think Leslie story really highlights you know the success of a liver transplant program and supporting someone through that change in you know massive change in their lives Uh but it is only a small fraction It's the tip of the iceberg in terms of the number of people that have [00:30:00] related liver disease or and cirrhosis that need treatment Um, you know the cornerstone of treatment is is alcohol with a view to abstinence there are limited kind of resources available in this country Um, and and the provision of those is very patchy so alcohol services in the hospital will deal with the acute problem Patch up the person and then connect them with the community services And then it's very much up to that that person themselves to follow that through And there are many places in which people can fall through the gaps and and fall back into their old habits of of heavy drinking Um so there's a lot of work to be done to The holistic care that we can provide for people with alcohol addiction but there are some amazing and people out there who are really keen to help Um there are growing number of lived [00:31:00] experience recovery organizations out there which um use peers who who have that experience the personal experience that they can relate to to help people guide them through their own challenges with cutting down and and stopping drinking Um and there are now a number of drugs that can be used to help support people reduce alcohol and and achieve abstinence and so some alcohol services are able to to use those as well to in in addition to behavioral support and behavioral interventions but the reality is that only a small fraction of of people with alcohol addiction and liver disease end up engaging with that service And that's one of the things that I'm really keen that we we tackle and we we've got a project ongoing at the moment is how to stop the people falling through those gaps that I talked about How to actually engage them use peers to to help um, support them through their [00:32:00] journey

James Morris: Yeah so important to try and maximize the opportunities across the healthcare system and and beyond even Um and Yeah of course there's the sort of prevention side as well and I think you know you'd both agree that we really need to as much as we can to address the kind of cultural normalization and acceptability of heavy drinking And you know we're seeing some progress in terms of More young people drinking less Um although the reasons are not really to do with um changes in policy So I think yeah we can do more in terms of controlling the environment less advertising availability and more use of Pricing restrictions which aren't always popular with the public but we do know from the evidence that those are important influences on the overall level of heavy consumption and um normalization of alcohol in society Um so yeah I think you know we've covered some really important stuff and you know had your story Leslie which is so [00:33:00] powerful and touched on some of the key aspects of what alcohol related liver disease is and and some of the the treatment opportunities Um do you have any final reflections Um you know As I said you know it's amazing that you can share your your story and your experience and and highlight as you did how it can kind of develop and how you know people often kind of maybe get caught out because it just seems a part of you know as we said work and de-stressing and so on

Lesley: I think you know when you look at the way that smoking has become such a you know The way that that that's gone And and you know I just think the money that's spent and invested in that I think they need to be looking at alcohol as well You know because it's not really sociably acceptable anymore to you know smoking was promoted and it was the way and you know even when I was working it was so acceptable Um and they've put loads of money into that and maybe they [00:34:00] need to be looking wider um you know to to looking at the damage of alcohol and the and the The fact that it's kind of hidden and um you know that people aren't looking after themselves as much Um and maybe starting you know educating people younger

James Morris: Yeah The the sort of comparisons often made and some people often do feel you know that the changes in terms of legislation and and culture and attitudes towards alcohol is maybe 20 years behind where we're at with smoking and but yeah a lot of the the changes in smoking have been driven as well by legislation increasing The price and so on as well as kind of shifting attitudes and the two sort of feed into each other So yeah I think that's a really important comparison because you know everyone's aware of how harmful to our health Um smoking can be and and the very direct impact um including on others But yeah still still more much more space [00:35:00] for alcohol to catch up in terms of full recognition of the hidden impact of of liver disease for one as well as many many other um conditions and and social and harmful effects Um and Ashwin do you have any kind of final uh comments or points that you'd really like to make in terms of um how we can kind of address alcohol related liver disease or broadly alcohol harms

Ashwin: Yeah I mean I think there are I challenges around alcohol that that we need to look at and address Um many of which we've touched on today in terms of um Promotion prevention of liver disease um reduction of alcohol use um through public messaging education we need better screening and and there is some some work going on around that as we discussed Uh and I and I think all of these challenges are are driven by stigma in different forms So I think [00:36:00] we really need Uh we need a strong voice of people with lived experience to to really speak out um on behalf of our patients to raise this as a a real problem in society that we need to address Um and it needs to be tackled at the very highest level people in in government um to try and change policy invest in treatment services Invest in um in ways to to help support people more widely not just with with medications and treatment but you know so social input and and structure and support as well So yeah I think, clearly the the challenge we need to deal with really is the is the stigma at

James Morris: yeah Yeah I absolutely agree with you that that stigma is a barrier to what we need on so many levels both in terms of individuals um you know Recognizing that alcohol users potentially are actually harmful and maybe seeking help or support as well as yeah the kind of [00:37:00] structural levels the lack of investment in treatment services and preventative policies as well And exactly as you say it's it's kind of people coming forward with their lived experience That the the best way to challenge that stigma That's what we know from from the evidence base So yeah I'm really grateful to both of you For for coming on the show I think that's there's so much really useful and important stuff in there So um again thank you so much Leslie for sharing your experience and thank you Ashwin for for all the work you do as well Thank you both

Ashwin: That's James for having us

Lesley: Yeah thanks for the opportunity