SCI Care: What Really Matters
SCI Care: What Really Matters
Finding meaning and purpose after spinal cord injury: Reflecting on 5 years of the Engage Program
Rebuilding a sense of meaning and purpose following trauma is a vital contributor to post-traumatic growth and adapting well to a spinal cord injury (SCI). This webinar shared the co-design process undertaken to develop a course that uses the concept of post-traumatic growth to foster a stronger sense of meaning and purpose after SCI. It presented the course facilitators' reflections on running the program for the last five years, its successes and challenges. Case studies were also used to demonstrate the impact of the course on participants.
The opinions of our host and guests are their own; ISCoS does not endorse any individual viewpoints, given products or companies.
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Okay, we can make a start. Hello, everyone. My name's Leanne Reese. I'm a physiotherapist based in Melbourne, Australia. I'm coming to you from the unceded lands of the Woundry people of the Kulin Nation. And I really welcome you all to the second ISCOS Psychosocial Special Interest Group webinar that we've been holding this year. I'm going to be hosting the session and just going to go through a few slides to begin with to introduce you to the SIG for some of you that may be new. If you could maybe put into the chat your name, where you've come from, it would be really lovely to see who we are. This event's open internationally, so we appreciate some time zones aren't favourable. So the session is also being recorded, but I believe we had over 100 people register for the session, which is fantastic. We've got Jane Duff on board who'll be monitoring the chat. So if anyone has any issues, please feel free to type in. And we've got Pete as well, who's helping us with any tech. So if you do have any issues with that, please let us know. So for those of you that don't know, we're the uh International Spinal Cord Society special psychosocial special interests group, and we're a multidisciplinary group. So doctors, nurses, allied health, people obviously psychologists, but we really believe that the psychosocial care for people living with spinal cord injury is everyone's business, and we all have a role to play in supporting that. And we we really aim to address that interaction of the social and psychological factors that influence the well-being and health of people with spinal cord injury. Our role as a special interest group is to promote psychosocial issues through ISCOS and the spinal cord injury community. And what we really love is that you don't have to be an ISCOS member to be a member of the SIG. Membership is free. And if you'd like to be on our mailing list, you can scan the QR code that's on this slide. But Jane is also going to put a link into the chat. We have two online webinars each year. We've also got a module on the eLearn SCI. And maybe Jane, do you want to put that into the chat as well? And this is a really comprehensive education tool for any health professionals working with people with spinal cord injury, not just psychosocial care, but it covers all the domains of health. So this is the governing panel that makes up the special interest group. We've got uh Jane from the UK, we've got Kim from the US, myself, Hallelujah from Tanzania who did our last webinar, which was really great. It was really interesting hearing about the experience of um psychosocial care in Tanzania. We've got Tyne from the Netherlands, Matteo from the US, Kathy from the US, um, and Angie from the US. So we're very US heavy, and you'll see that we've got a couple of vacancies, and we would really love to um we we we uh used to have someone on the panel who had lived experience with spinal cord injury, um, they've had other commitments and had to leave, but uh we're we're really looking for someone with spinal cord injury or other otherwise representation from other health professionals as well. So we're kind of covered for allied health and psychology, but looking for any uh nurses or doctors um out there, that would be great. And if you are interested, um you can email this uh iscos.psychosocial.group email, and maybe Jane, if you wanted to put that one into the uh chat as well. So just giving you an overview of this year, we've currently got 112 members on our mailing list, um, which is fantastic. As I said, you don't need to be an ISCOS member to join. We've got uh we've more than doubled our LinkedIn profile with 278 followers now. So if you are on LinkedIn and interested, it's a really great way of keeping on top of the activities that we're doing. Um, at the ISCOS ASM that was held in Gussemberg uh last month, we had a workshop and a poster that went really well. Um, the basic psychological functioning data set has now been accepted for publication, and thank you to Marcel Post for his leadership on that project. The extended psychological functioning data set is being led by Tyne and Kim, and that's coming along really well. Um, and then each year we have the Professor Paul Kennedy Legacy Award for Psychology. Um, so this is a yearly award, and the recipient for this year was announced at the ACM last month. So um please keep an eye out for this award for next year. It will be um announced after oh uh early next year, Jane, actually.
SPEAKER_02:Or shortly after the early bird is announced from the from ISCOS from the um ASL team.
SPEAKER_00:Okay, great, thank you. Um information about this award is available in Chinese, French, Spanish, um, and English, but the application is in English, uh just to let you know. And this is to fund someone to attend an ISCOS conference, um, so it includes travel and accommodation, or if they would prefer, um, attend a skills-based training course. Um, and then uh they would then present their learnings of the ISCOS meeting and an opportunity to connect with ISCOS Psychosocial SIG is an essential component of the award. Um, it's really there to support early career psychologists working in spinal cord injury and particularly those from lower-income countries where attending the ASM might otherwise be difficult. So if you're wanting some more information, you can email the email address below, and Jane will put that in the chat also. Um, but uh just to profile some of the previous winners. Um, we've had representation from uh Chicago, Bangladesh, uh, Ukraine. And then we had Hallelujah from Tanzania, and the the winner this year has come is uh Dr. Danny Brent from South Africa, um, looking at mentoring to help integrate psychological services into SCI rehabilitation. So Danny will present to us next year uh on his findings, and as I said, please keep an eye out for the next year's award. For those of you who are ISCOS members, it'd be really great if you could add the psychosocial seag hub to your profile. Um, this is a new addition to the website. So to do that, you just need to sign in and you should have your sign-in details. And then once you've signed in, you'll see at the top of your screen some um different headings. So if you went to groups and then scrolled down the page, um you'll find the special um the psychosocial special interest group. And then on the bottom left-hand corner of that box, you just click on the join group, and then you'll um it will come up as part of your profile each time that you then log in. And that way you'll keep up to date again with um activities that are happening. Jane's gonna put a link into that um into the chat. And also um it won't guarantee uh sorry, joining um the SIG via the ISCOS website won't put you on the mailing list though. So we haven't quite got that far in the technology yet. So if you wanted to be on the mailing list to ensure that you received information about the webinars, um please scan this QR code. Okay. So housekeeping for today's session. Um if you haven't already, please um enter into the chat where you're from and uh your name and maybe where you work. If you feel comfortable to keep your cameras on, that would be great. Um obviously we won't see everyone during the presentation, but at the end of the presentation we'll we'll um stop sharing the PowerPoint and then if that's an opportunity to switch your cameras back on so we can have an interactive QA, that'd be great. The session is being recorded though, so if you weren't comfortable in having your face recorded, then please feel comfortable to keep the camera off. If you have any questions along the way, please post them in the chat and Jane's going to keep an eye on that. Otherwise, there will be an opportunity to um ask Google question if you prefer to speak. The closed captions has been enabled, so at the bottom of your screen, you should be able to see a button that will enable that for you. I've mentioned that Pete from MISCOS Events is here with us to provide us with any IT support. So if you're having any technical difficulties, please let him know. Um, and we would love your feedback at the end. So um, there will be another QR code that you can scan to a feedback form. So please stay to provide that feedback. All right, it's my great pleasure to introduce to you Dr. Emily Bray. Emily is a research fellow at the Hopkins Centre at Griffiths University in Queensland, Australia. Emily is passionate about using participatory and co-design methods, and her current research focuses on understanding people's lived experience of transitioning from rehabilitation to the community and supporting psychosocial adjustment after acquiring disability. Today, Emily is will share the co-design process undertaken to develop a course that uses the concept of post-traumatic growth to foster a stronger sense of meaning and purpose after spinal cord injury. And I read about this project um a few years ago, and I've been probably a bit selfish in nominating Emily to talk to us today because it sounded so interesting, and I'm really um excited to hear how this program has gone. So I am going to now hand over to Emily. Sorry, let me just go. Okay, Emily, you should be able to have the controls there now.
SPEAKER_01:Wonderful. Well, thank you for the introduction and and thank you for inviting me to speak today. Um, I'm gonna be talking about the engaged program which I run for an organization called Spinal Cord Injuries Australia here in Australia. Uh uh, they're based in Sydney, but I'm in Queensland. Um so I'd like to start by acknowledging the traditional custodians of this land where I am today. Uh, the First Nations people have long engaged in ceremonies of storytelling, music, dance, and celebration. And we pay respect to the elders past and present and recognize those of the future who will carry the memories, traditions, and aspirations of First Nations people. It is crucial to remember that beneath the concrete and asphalt, this land always has been and always will be traditional First Nations people's lands. We acknowledge the contributions of both First Nations people and non-First Nation Australians towards building and advancing a sustainable future, promoting health, reducing inequalities, and achieving better social outcomes. Um, who am I? Who is SCIA? So I'd like to just start by introducing myself and my background. So I'm a social worker here in Australia. I have experience working both in the rehabilitation uh side and the community setting, um, focused on neurological injuries, mainly spinal cord injuries and brain injuries. I'm also a researcher at the Hopkins Center in Queensland, Australia, um, whereas I had mentioned before, most of my research focuses on psychosocial um aspects of uh living with a neurological disability, again, mainly brain and spinal injury. And this is particularly important for me because uh I'm very passionate about supporting people with neurological injuries live life to their fullest after spinal cut injury because I have a lived experience of spinal cut injury. So I acquired a C5 uh complete uh injury back in 2012. Um and while it's challenging, I have uh found that uh life after spinal cord injury can be really fulfilling. I am now a wife, I have two beautiful children, I still enjoy books and reading books, and I've recently become quite an NRL enthusiast at the insistence of my husband. Um, and for those of you that are in England, obviously we've been watching the Ashes over the last couple of weekends. So um SCIA, who is SCIA Spinal Cord Injuries Australia, who I work for doing these engaged the engage program, is a for-purpose organization working for people with spinal cord injuries and other neurological conditions. We offer a range of services, including peer support and family support. We do physiotherapy and EP in the community, we support people with employment, we do advocacy, um, we provide some support with the NDIS, which is the insurance scheme, over here in Australia. We've got mental health support and also some social enterprise activities, which includes the taxi booking system in New South Wales. Um, I work within the resilience and inclusion program department. Um at SEIA, we believe that building resilience and finding meaning in life is essential to wellbeing. So we offer two free resilience programs that are designed to help strengthen mental health, build resilience, find meaning and purpose, and connect with others. Um, and we also offer further guidance to support people in accessing counseling and navigating the mental health system. So the two resilience programs that we run, one is called EPAT, which is a self-led online skill building and educational course, which is designed to support people with spinal injuries who are experiencing symptoms of depression and anxiety. And it was developed using the principles of cognitive behavior therapy. So I'm sure as many of you know, if you're a psychologist or counselor, it's a therapeutic approach that builds on the idea that if we can identify and challenge negative thought patterns and replace them with more realistic and positive ones, we can in turn change our feelings and behaviours. It's a brief summary of the EPAC program. And then the Engage program, which I'm going to be talking in detail about today, is an online group program that uses the concept of post-traumatic growth as a framework to support people with spinal injuries in finding meaning and purpose. So, my plan for today is I'm going to talk about the co-design and development of the course. I'm going to talk how we use post-traumatic growth as our framework throughout the course. We're going to do some uh reflections from both uh past participants, so some case studies, and then also some facilitator reflections uh from the past five years or so running it. So, design and development. So, I'd like to introduce you first to the research team and really acknowledge the significant input that they put into designing this. So, we have Professor Phil Siddle, who is quite prolific in the world of pain management and has uh many years' experience as a researcher and clinician in the field. We've got uh Sky Dong, who's a psychologist with extensive experience uh supporting people with spinal injuries. Rebecca is a physiotherapist who specializes in pain management and spinal injuries, and then associate professor Shane Clifton, who works at the Faculty of Medicine at the University of Sydney. And Shane also has lived experience of a spinal cord injury. And then you've got myself as well. So Shane and myself were highlighted in red as we were the two members of the research team that had lived experience with spinal cord injury. Um, this role was completed in the roles of the Hammond Care and was funded by the iCare Foundation. So I personally believe that one of the most unique and invaluable parts of this program is the importance placed on lived experience, both in the design and in and in its running. And uh prior to doing this presentation, I reached out to the team just to say, I'm going to be doing this presentation. So anything in particular that you know feel that I need to stress or you want me to say, you know, other than you know, what we've spoken about and presented about in the past. And Phil came back to me with this wonderful quote that I thought I would share with you because I think it also emphasizes the unique and invaluable part that co-design had it had in this uh program. And he said, I think our experience was that co-design was critical to developing a good program. I can't see how it would have been possible to achieve the richness and relevance of the final program without input from people with SEIA, SEI even. We were incredibly fortunate to have input from you, Shane, and Nick on the team as well, not just in consultation, but also having direct involvement and input in the design, development, and delivery. For me, this was huge, as well as making the whole process very enjoyable. Um, so I think that really nicely sums up the the pro not the process, but the experience and the importance of developing the program. So the program was developed using a participatory research approach, which embedded co-design methods. Now, the idea of participatory research has attracted increasing attention and enthusiasm in in recent decades, and I'm sure we you've heard about it a lot uh as well. It's a research process in which people with lived experience and researchers partner to plan, design, conduct, disseminate, and implement research. The push for participation in part stems from the growing recognition that partnering with people with lived experience enhances the relevance of research priorities and outcomes. So it improves interpretation, therefore facilitating a more accurate representation of reality and can increase the value of the research for the end user. Not only does involvement in the research process empower those involved, but it also increases the likelihood of the project sustainability. There are many participatory approaches with concepts and terms used often interchangeably. I think two commonly used approaches are co-design and co-production. They vary slightly. Co-design recognizes the value of experiential or lived experience in the design of services, and co-production extends this to delivery and evaluation. So they emphasize the insights from lived experience, they value collaboration and collective decision making. They uh address, also address the unequal power arrangements between professionals and service users. So they're now both increasingly understood to be very critical in design, delivery, and evaluation of services for and research for people with disability. So there are many ideas, you know, in people that have put it, you know, developed steps to co-design. Um but here is one approach by Kay McKerchar at the Murdoch Children's Research Institute here in Australia, which I think uh details the process nicely. And it is something that we followed for this project. And what it sets out in the process is to first start with building connections. So developing a team, who is the right team uh for this project? Um, do we have support from the community, support from organizations, uh community organizations? Are we working on a project that also matters to this community? Step two, immerse and align. Should we be doing this? What do we already know? Scoping out the literature, who should be involved, where are the gaps? Step three, discover. So, what's already happening? You know, what are we doing well or what's being done well in this space? Uh, what are the gaps? What are the unmet needs? What do people want? Step four, design. How what are we going to build? How are we going to build it? How are we going to improve on on what's already there? Testing and refining, and then finally implementing and continuing to learn. And I think that even though I guess the official research project has ended it, ended back the in the end of 2020, you know, SCIA continue to implement it. And hopefully we continue to learn from the feedback we get from participants. So even though the formal research process is finished, I feel like we still kind of circulate in this implement and learn stage as we continue to run the program. So if we take this kind of process and look at what we did for the research project and the design of this program, we built connections by establishing an advisory group that supported us through the life of the project. We amassed and aligned by conducting pre-development consultation workshops with people with spinal cord injury. We then used those also to discover what people want. We then designed the program, tested and refined it through two pilots, pilot it, revise, pilot it, revise again, and then we transitioned the program to SCIA, where we continue to implement and learn. So going a little bit more in depth, what did the advisory group do? So the advisory group provided general counsel across the life of the project that played a really central role in key decisions. So looking at the mode and timering of delivery, program content, recruitment, um, what the program's long-term future is going to look like. And so we made sure that we had representation right across the field of SEIA, SEI. Um, so government and policy organizations, um, hospitals, like rehabilitation centers, outreach teams, community organizations, and also people with lived experience. In terms of the pre-development lived experience workshops, we had one three-hour workshop with eight participants and then four individual interviews. And during those workshops and interviews, we explored the concepts of post-traumatic growth, meaning, and purpose. And we discussed the planned content, we discussed delivery and recruitment. And in summary, what we uh covered some of the themes that came up during those uh workshops were that the program needed to be evidence-based. It needed to include activities, pictures and videos and be interactive. Ultimately, face-to-face was preferred, but participants understood that online would probably be logistically favored for many. They wanted to see small groups that really focused on conversation and sharing stories and connections. Uh, they wanted it to be facilitated by people with spinal cord injury. And then in terms of timing for delivery, they thought that it would probably be best that individuals be at least one year post-spinal cord injury, so that they had gone through the rehabilitation process. They felt that people are often really well supported during that rehabilitation time. They've got psychologists and counselors available as an inpatient, your physios, your OTs, etc. And this was probably a really good program to be offered when people are back in the community. Maybe they've settled in and they're now looking at, well, what do I do next? Based on these workshops, an overall summary of what the engaged program looks like. So we developed this 10-week intervention where we had six weeks of two-hour group sessions where we focused on content and looking at post-traumatic growth and the different aspects of that. We then offer three one-on-one coaching sessions where we take that content and apply it to each individual and what they're going through. And then we come back for a final week and do kind of a reunion. What have we learned? What have we, how did the coaching sessions go in and kind of sharing? So it was all designed in a way that we explain the concept of post-traumatic growth, we address trauma and grief, and then we look at the meaningful life, personal strengths, relationships, and activities. And in developing the program, what we also did to support the program is develop a series of videos where we interviewed people with spinal cord injuries on varying levels and at varying times since injury about their experience of post-traumatic growth. Um, so there's eight to eleven in total, I think. I can't remember exactly. They're all on the SCIA website. They're about 45 minutes to an hour long each, but we also cut those down to have videos that addressed each of the topics that we would go through in the six content group sessions. So if you didn't want to watch a whole video, you could just watch one on what everyone said about relationships, for example. And these really supported us in the program, and they continue to do so. So we're gonna talk a little bit now about post-traumatic growth and how we use it in the program to guide learning. Um, so I'm sure as you're all aware, sustaining a spinal foot injury is really life-changing. And it brings about substantial physical, social, and psychological consequences. So not only are individuals required to adapt to the considerable physical changes and complications, they also face psychosocial losses and challenges, including loss of independence, loss of personal control, changed social. Rules and status and changed identity. Yet, despite this, research shows that through a process of adaption, there is the potential to experience positive psychological changes, namely post-traumatic growth. Post-traumatic growth has been defined by Tedeschi and Cologne as positive psychological change experienced as a result of the struggle with highly challenging life circumstances. So, one notable aspect of this definition is that growth is not arising due to the trauma, but it's due to the struggle with its aftermath. It encompasses both positive and negative elements. We're just saying that there might be areas in your life where you can see that you have grown positively. And through this cognitive rumination process, the individual attempts to make sense of their experience and develop a revised core belief system that integrates their new experiences. And this can lead to post-traumatic growth. And this growth is proposed as occurring across five main domains. Generally, it happens that people gain a greater appreciation for life or change priorities. Perhaps there's a greater sense of personal strength, there's a stronger sense of meaning or purpose, spiritual or existential development, perhaps greater connections with others or a higher power, or the identification of new possibilities or opportunities. Growth doesn't have it have to happen across all of them. Could just be one or a few, could be all. But research has confirmed that there is a potential for post-traumatic growth following spinal cord injury in all five domains. So what we do for the Engage program is use this framework to guide our conversations. So across the 10 weeks, we kind of look at a different element of that post-traumatic growth, those five areas. We start with just a general introduction, you know, the who are you, what brought you to this program. We then look at growth loss and trauma, what a meaningful life is, our strengths and virtues, relationships and activities before we move into coaching. And I'm going to go through each of those kind of in turn just to explain a little bit about how we do that. So I'm going to jump into session two about grief, loss, and trauma. This is, I think, a really important session for people because I think the only way to move forward is to actually start by acknowledging that spinal cord injury is really hard, it's really challenging, and there will be feelings of grief, loss, and trauma, and this is often where people are at when they start the program. So we talk about the theories of grief. We look at an exercise that uses pictures and art to explore our grief, using pictures as a way to um communicate how a spinal corn injury has impacted us. So grief is this complex process of adaption. It's a unique and individual process, it's influenced by cultural, familial, and other social contexts. We talk about how social grief uh successful grieving doesn't mean letting go, and uh it's primarily a process of reconstruct reconstruction of meaning. So we look to challenge unhelpful beliefs about grief, the thoughts of, I thought I was strong. You know, when people say you've got to get over this, you've got to get on with your life, or they're having these thoughts. The thoughts of, you know, I've just got to snap out of it, I've just got to go over this. And instead, we help to help people upstart at least the journey of understanding that grieving is a process of adjustment and a new learning that cannot be hurried. There's no quick fix to grief, there's no right way to grieve. You know, it's not an illness with a prescribed cure. Grieving is really healthy, it gives you time to adjust to the life that uh with the losses that you've experienced. And we we talk about grief being more of a volume control than an on and off switch. So there's time in our life where grief might feel heavier because you have gone through an experience. So, for example, we use perhaps you've become a new parent and your the way that you are parenting doesn't look like what you thought it would be when you were able-bodied. And that really turns the volume up on your grief. So we talk about what strategies, um, coping strategies, well the strategies can we implement when the volume of grief has been switched up high, so that we can turn down that volume of grief and still learn to go on with our uh with our days by acknowledging that yes, I'm experiencing grief. I'm uh life is hard right now. It's not what I uh there's losses that I'm I'm I'm dealing with, um, but how are we going to move forward? And I love this image of you know how we want the grief to work and what it actually looks like, and that it's what we're trying to kind of portray in this volume switch of grief. Um in session three, we look at what makes life meaningful. Um and in this ex in this session, we ask people to identify things in their life that are meaningful. Um and through this, we uh people always, you know, sometimes people struggle and say, I don't think I can find anything meaningful. Sometimes they say, Oh, my friends, my family. Um, but often what comes up across the board, which mimics research, is that relationships are normally the top thing for everyone that makes life meaningful. Um and uh we use the research not only to highlight how what they have brought up in their own thought process mimics relationships, but also to show them what other things they could be thinking about that makes life meaningful. We then discuss why pursuing meaning is important and we link it back to spinal injuries. So, one of the studies I talk about is one in which um college students were asked to pursue either meaning or happiness over 10 days by doing one thing to each day to increase it. So some of the activities in the meaning group included forgiving a friend, studying, helping or cheering up others, um, where the happiness group would do things like sleeping in, playing games, eating candy. And although the students in the happiness group experienced more positive feelings and fewer negative ones immediately after the study, three months later their mood boost had faded. Where uh and where students that focused on meaning didn't feel happy right after the experience, which kind of makes sense, you know, meaningful pursuits like helping a friend require sacrifice and effort. Um, yet three months later they felt more enriched, inspired, and part of something greater than myself. They also reported fewer negative moods. So over the long term, it seems that pursuing meaning is more deeply satisfying than chasing happiness. And I kind of relate this back to the idea of I think sometimes it helps people, you know, if you eat a piece of chocolate, you're gonna feel really great in the moment, but that might not improve your happiness tomorrow. So that's kind of what the what we're looking at. So instead of eating chocolate, maybe you want to have a conversation with a close friend about what you're going through, and that might have more long-lasting impact in terms of your well-being. Although it's nice to think about okay, what makes life meaningful, it actually can be quite a difficult concept for people and feel quite overwhelming. So, although we talk about what makes life meaningful, we do at the end try and refocus it and reframe it by focusing on the day-to-day improvements that lead to quality of life. And we use the concept of Ikigai, um, which is delineated in Japan and Okinawa, Japan, um, which is uh a blue zone, which is a zone, there's there's five across the world, and uh there's um within those zones, people generally tend to live longer and have better uh out like health outcomes. Um by the by, but um the concept of Ikagai is really helpful for helping people understand that it's a reason for being, that is translated in a reason to wake up for in the morning. And it's discovered in doing simple things every day, tending to your garden, looking after children, doing some arts and crafts, taking care of your dog, um, taking care of pets, etc. And this is really helpful for this session because people are able to relate to that. Sometimes thinking about what makes life meaningful, quite an existential thought process, but thinking about well, what can I do today that's gonna get me out of bed? Well, I have to let the dog out to do a we. So my dog is my sense of meaning and purpose today. Um in our next session, we start to look at strengths of character, and we use virtue ethics as a way to do that. Um, virtue ethics and this session was put together by Shane, who is a theologian, I think it's a theology theologist. Um uh and uh it's really was his baby, and it took me a long time to get my head around it. But in summary, we uh virtue theory is a way of understanding morality that focuses on being a good person rather than just following rules or judging actions by their results. So it comes from philosophers like Aristotle, who believe that living a good life means developing um positive character strengths or virtues. So down the middle column you can see courage, generosity, um, kindness, and wisdom. And these virtues help people achieve eudaimonia, which means living well or a life of flourishing. So, modern psychology, particularly positive psychology, this idea connects closely with the concept of character strengths. So qualities like bravery, curiosity, and gratitude that reflect these same virtues in everyday life. Um, so by identifying and practicing our strengths, we can build good character, make better choices, and live a more fulfilling life. So, in this way, virtue theory and character strengths both focus on personal growth and becoming the best versions of ourselves. So during this session, um, we look at the strengths that we may have, trying to identify those. But virtue ethics and and character strength, they talk about this golden mean, how you can have these virtues and strengths, but sometimes you can show a deficiency in that might come across as cowardness or an excess, and that might look foolhardy. Um, so we we talk about that in regards to spinal injuries, and one that normally people relate to is anger. After a spinal cord injury, sometimes people are very angry about what's happened about their lives, and sometimes that comes off in excess um towards the wrong people. Um so we talk about how building our strengths and trying to live a good life is perhaps about understanding that anger sometimes is best used at the right time, in the right way, in the right amount towards the right people. So, for example, getting angry at your support worker might not necessarily achieve the right um outcome that you're looking for because you're perhaps relying on them to uh support you in and if you're then angry in in a way in a situation that doesn't require it, might not result in the in the outcome that you're looking for. Um or in a insurance systems are different depending on where you are in the world. But here we have the NDIS process is involved in the NDIS, you call up, and you'll probably talk to someone that has no influence at all over your funding, and probably is just the funnel to sending your information off elsewhere. Getting angry at this person is likely not going to result in anything more than getting you getting hot under the collar. Um, so we're talking about how we can use our strengths in different situations, um, but that one tends to resonate with people. Um the next session we look at relationships. Um social support is a key factor in people with spinal cord injuries experiencing post-traumatic growth. So we look at what meaningful relationships people have before the injury, what meaningful relationships they have now or after their injury, and we look at what makes those relationships important. Generally, it's the fact that they give you a sense of connection and they give you a sense of belonging. Um, and again, all sessions are hard in different ways, but this one can also be particularly hard because people don't seem to identify I don't have any support. There's no one, I don't have anyone. So, what we try and do, we break it down into four levels of their support. So you have your emotional intimacy level, which is maybe just one person that you can confide in, um, a best friend, a parent, a significant other. May not be a person, it could be a pet, it could be a spiritual god. We then look at friendships, having someone in a friendship level. So, friends, we we talk about how they come in all shapes and sizes. Sometimes you have friends that you've had from childhood, others come into your life later and uh only there for a while, and that's fine. But do we have one friend that we could put in that level? Um participation, people you interact with but would not call outside their interaction. So um perhaps there's someone at work that you have lunch with, but you're probably not gonna call them outside of work. Um sports groups that you're involved in. I think parents groups are a good example of that. Sometimes you go to a parents group and you talk to uh the other parents there, but you're not actually gonna call them or interact or go for coffee with them outside of that. And then lastly, the exchange group. So, someone you pay for a service. This could be your local barista and it could be your psychologist, it could be a social uh support worker, it could be your um physiotherapist. Um we try and support people in identifying at least one person in each of their categories, and when you break it down like that, normally people can find one and people start to acknowledge that you know what the connection that I have with my barista every morning, just that hi, how are you? How's your day going? Look at the weather, those interactions are just as important as the emotional intimacy because they provide you a set sense of connection for that day. Um, not only do we look at you know people, but the defining features of a meaningful life are connecting and contributing to something beyond the self, which yes could be a person, but it could be nature or God. And so we also talk about spirit, spirituality, faith, and nature. And there's one research study that I draw on for this topic, um, which is a study that looks at people's recovery in hospital after minor surgeries, when they're either placed in a room with no windows or a room which has a tree view and windows. And the patient with the tree view in this study had shorter post-operative hospital stays, had fewer negative evaluative comments from nurses, took fewer moderate and strong analgesic doses, and had slightly lower scores for minor post-surgical complications. Um I find this as a really nice way of showing the impact that just being able to see a tree outside the window has on our recovery, but also that it can have on our mental health. Um so through this relationship session, we'll look at looking at not just the relationships we have with other people, but the relationships that we may have with nature, with music, with art, with a god, whoever it may be, just something that you can connect to. In uh in session five, all right, um, we look at activities um and what makes activities meaningful. So after kind of having a conversation about what activities are meaningful for you, we then talk about okay, well, what makes these activities meaningful? Meaningful activities are generally aligned with your values, your passions, your strengths, skills and beliefs. They're challenging, creative, uh, they might have some intrinsic value, uh, feel productive, rewarding, they often involve a sense of connection and belonging, and they often involve making a contribution. Um we talk about the science of contributing. Um and one of the studies that I use for this looks at how generous behavior is known to increase happiness and therefore motivates. So in the study, I talk about how. Um participants promise to spend money over a series like a timing of four weeks either on others or themselves. And the results say that participants who spent money on others make more generous choices uh long term and also show stronger increases in self-reported happiness. So we talk about how we can do activities that contribute to others and give back to the community. However, also in acknowledging that sometimes that requires a lot of effort, both mentally and physically. And so we also need to do activities that fill our tank. So make sure we're doing self-care and activities that uh recharge our batteries, things like that. So it's about finding a balance of both. Um and then in this the coaching sessions, we turn all of this theory, all of these conversations that we've had, the what are your passions, the what are your strengths, how can we make a contribution, how can we connect and belong to others, and we bring it all, all the puzzle pieces together into one nice picture. Um, we talk through the learnings and we set goals. Um, sometimes we don't even call them goals because goals sometimes is a little bit like people like I'm over goals, I don't want to set any more goals. So we say, okay, well, let's set some intentions. Let's and we just change the learning, and that seems to have worked really well. Um look, what is important is that throughout the program we continuously come back to this image and continuously you know, show okay, why are we talking about relationships? Well, let's look at the post-traumatic growth tree. Connection with others and higher power is is generally a growth that tends to happen for those that achieve post-traumatic growth. And we say, okay, we're we're looking at moving forward, we're looking at engaging in self-reflection, we're looking at how we can engage with others and how we can engage in activities. So we send people away homely with goals of okay, well, I want to, you know, uh get back to water skiing. Okay, well, great, what does that look like? You've loved it in the past, you've wanted to um you want to get into it now, or how can we explore that? Um okay, so we've created this program. I've explained the program. I'll talk a little bit about the results from the piloting of it, um, and what we found. So we in back in 20, this is back in 2020 now, we ran two pilots, one with six participants, four male, two female, mean age 61, uh, quite a range of uh levels 50-50, complete incomplete, and 10 months to 43 years post-injury. The second seven participants, I think what's interesting about this is that they were all incomplete injuries. It's normally unusual to have all, um, but again, wide range of years post-injury. Um we did uh it was a mixed methods study. Quantitative measures were taken pre-program on completion of the program content, and at three months post-program. The qualitative data was done post uh at three at the three-month time point. Um, we looked at uh the quality of life measure, satisfaction with life, physical and psychological well-being, spiritual and existential well-being on the facet and mood. And then the interviews were to describe participants' experience of participating, the perceptions of connection to the interventions core concepts, and their strengths or perceptions of strengths and and areas for improvement and um and what we found. Um so with the quantitative results, I ask you to bear in mind that the numbers for this pilot are very small. So we can't really say anything in confidence in terms of statistical significance. So I'm giving a bit of a brief summary for those that are interested. Um but basically the largest change was in meaning and purpose on the Basset spirituality scale. Um then we had change, uh the next significant change was in satisfaction with life. I say significant, not in that terms, I don't think it was statistically significant, but it was another of the largest changes. Changes were smaller, um, but still reasonably large on the physical activity and uh psychological uh SEI quality of life basic data set. Um, and then there were smaller changes in depression and stress on the DAS and overall quality of life. I think what was most like of all of these, I mean, there's positive results across all of them. What I think was most interesting was actually anxiety, which increased slightly immediately following uh the program, but then improved um at three months post. So you kind of think, okay, well, uh and then this is just hypothesizing, but was it anxiety because the program was ending and they didn't have the sub the support that then went back down to a base level where they realized actually, you know, I've incorporated some of these learnings. I'm I'm not sure, but I think that was probably the most interesting um result for me. Um and then these are some of the qualitative results that we've published. Um, and I'll run you through these quickly. Um so the themes show how participants were drawn to the program because they longed to connect with others in similar situations and with more experienced facilitators. Participants then reported engaging in a shared group process, journeying with others through reflection and learning, and exploring concepts related to post-traumatic growth and meaning. They reported that this was the first time that they truly had had the opportunity to reflect on their lives after their injury and explore these concepts. And the knowledge that they gained was empowering. However, they found that the opportunity to explore the concepts, um, you know, brainstorm and process them as a group was really vital. And sometimes it was actually really hard to think about them on their own in their own space. Um, being open, honest, and vulnerable was difficult for some participants. However, hearing other stories gave them the courage to speak about their own experiences. And in turn, this made them feel heard and seen and validated their feelings of grief and loss and trauma. And some participants sometimes found it hard to move on from these conversations during the session and kind of return to the topic at hand. Participants also reported engaging in an individual journey where they connected the different elements of the program to their personal circumstances. So for many, this was recognizing and acknowledging the role that grief had in the process of acceptance and adjustment, acknowledging that these feelings may not go away, but they can develop coping strategies to help them turn down the volume. A few participants had trouble with the concept of quality of life and were searching for what that meant to them post-program, but they continued to think about two questions. What gets me out of bed in the morning and what fills my cup? So the concept of meaning and purpose and quality of life were quite overwhelming for people in the program, but focusing on those day-to-day improvements, those day-to-day things, led them to have more of a sense of control over their situations. Relationships were difficult to discuss as a topic, but they could link the complexity of change relationships to feelings of grief and loss. And the coaching sessions provided participants with an opportunity to translate program concept into specific goals that facilitated their personal psychological and spiritual growth. Post the program, participants recognized that you know, post-traumatic growth is an ongoing process. They continued to reflect on the program's concept and incorporate them into their lives. And some participants said that it's quite difficult for them to continue on their own and that they would need ongoing support from spinal cord injury community, peer support, professional therapy. But that discussing these concepts gave them hope that they would adapt to life with a spinal cord injury and uh started the process of kind of meaning making for them. So following the the pilots in the transition to spinal cord injury, as we continued to refine it, um, we thought it was important to develop a handbook for participants, but also facilitators. Um we did a bit of a slide update, we introduced breakout rooms, um, end of session reflections, and the opportunity to for continued connections using a WhatsApp group, um, but also what we called alumni events, which I'll touch upon a little bit later. So I'm gonna just reflect on a couple of participants' experiences um as case studies. Um firstly, since the end of the pilot in 2020, um, so the last four years, we've typically run two programs a year. We've had 49 participants come through the program in those four years. Interestingly, majority of which are female, um, which, if you know, if you've done research in SCIA, it's that's a little unusual. Um, typically it's more male dominated. Um, so I do find that interesting. Um we don't kind of do research on the program anymore, but we do do kind of feedback um surveys at the end just to make sure that you know, gather people's feedback. What did they think about the program, etc.? So generally uh from the last four years, we found that over 70% felt the engaged program was very helpful at improving meaning and purpose in life. Over 80% felt that it was helpful in improving connections to people with lived experience, and over 90% would be extremely or very likely to recommend the program to someone in a similar position. Um, I'm gonna now when I was preparing to do the presentation, I emailed three past participants to kind of ask them to reflect on their time. So I'm gonna talk about Sarah Jane first. Um, and I asked them all how did you how how were you? Where were you at before you started the program? Um, and Sarah said there did not seem to be much in my life to motivate me to get out of bed some mornings. I was experiencing isolation and a sense of being lost. I was merely surviving. She was looking to find direction and to move from merely surviving to thriving. Um when I asked about the the framework of post-traumatic growth, she said it provided the program with authenticity, it validated many points for her, and that having a facilitator with lived experience seemed to give the content more credibility. The program gave her something to look forward to each week. She experienced the benefit of sharing and connecting with other participants as they discussed their mutual struggles and understood each other's experiences. We connected deeply, free from the identity crisis that often accompanies the profound effect of spinal cord injury. So this is SJ. SJ is now one of our peer and family support coordinators. So before doing the program, um, she was unemployed and obviously struggling to find her purpose in the world. She said it rekindled a part of me that I had forgotten. She set a goal to find meaningful work, became active in advocacy, and a few years later, um she accepted a position with SCIA as a peer and family support coordinator. She runs the Blue Mountains and Central West area. And she now, as of last year, run co-facilitates the engaged program with me. Um she's a wonderful facilitator. She was facilitating and running adventure programs before her injury. Um and so now I'm very excited that she's kind of gone through this journey, found herself, and has now, you know, come out on the other side and running the program with me. That's SJ. Um SJ did the program, I think, four years ago. So she was one of the first people to do it. Um, and then talked to Barbara, who had only done it at the beginning of this year. Um and she said before the program she felt disconnected and disengaged. She'd been searching for answers as to why she was feeling that way and couldn't understand uh her challenges and didn't have the tools she needed to regain strength to flourish. Um, she wanted to learn skills and develop tools to cope better and create a better future with the options that she had. Um talked about how hearing other stories gave her a sense of understanding and belonging and motivated her to keep working on the daily challenges. It was a safe space to share and learn. Um, each key topic helped her explore her feelings and experiences and gave her hope to continue growing. Um and this is Barbara. Um she put together lots of goals for herself. Um, I think hoping to have fun and adventure again, even when I thought it wasn't possible, was my favorite goal, is an ongoing goal that I can achieve over and over again. Um, I really liked that. Um, and she's now doing some advocacy work, I believe. Um, but understanding the process of change after trauma has allowed her to focus on supporting herself positively and proactively rather than being sad and feeling like I'm not coping. I see life in a better, more positive way now. And lastly, David. David also did the program about four years ago. He was in a pretty low place when he did it. His wife had just left him um after his injury. Um and he just wanted to heal and feel good again. He met lots of great people that he's kept in touch with. Um, and he got he just talks about how he he got so much strength from seeing how others were coping and managing. Um he learned to be great for this life. And he said it was hard at first, but with the help of the engaged programs, he's come to terms with um his injury. Um, this is David. Um, after he completed the engaged program, he knew he wanted to do something to help others. Um, so he's now a member of the board of SCIA. Um, and his particular passion is extending Sydney's services to regional and rural areas. So he works with the advocacy team, particularly to do that. Um, he's a farmer out in rural Australia, so he's returned to farming now as well, which I think is is fabulous. So um hopefully you can see through those stories the journey that people have gone on through participating in Engage. Um, and I'd lastly just like to kind of reflect on my learnings from doing the Engage program over the last five years. Um first to first, just those day-to-day things. I think that the program is uh really aligns with SCIA's values, which I think is a benefit and makes it easy to run. You know, we we want to support people with SCI and re-engage in life, and we want to promote also the lived experience and having facilitators with lived experience. Um, the program is unique, I think, and novel. Um, it addresses the need for more psychosocial interventions. However, I do acknowledge that you know dealing with the psychological and existential issues in a meaningful way requires substantial space and support. And as such, ongoing individual psychological therapy may still be required. So make it very clear to participants that the program is not intended to provide individual therapy, but provide them with the tools and resources to address their own needs, and then we encourage them to seek further support if they need it and would provide them with the resources to do it. A challenge that we always face is recruitment. Um, we're constantly trying to advertise. We'd like to run the pro the program with at least six people. Um we find that if we have eight people registered, six people would turn up. Likely is if we have six people registered, four people will turn up. We don't like to run it with any less than four people. It's really not cost-effective and it doesn't allow for uh that exchange and connection and and conversation to happen. So uh although we've been successful to date in getting at least six people or so, it is a challenge and it's it takes a lot of time and effort to get people together. Um the cost is minimal. I mean, we were very lucky that was this was set all set up through uh or developed as part of a research program and it is funding. But if you think about the the time of recruitment, getting people involved, running the program, um, it can add up. So if you're an organization looking to do a program like this, I think you've just got to be wary of the cost of setting up the program, um, but also continued running of the program. Um online delivery is definitely essential. If it was in person, we would definitely struggle with recruitment. I think online um is for us the only way to go. Um I think a strength is that it's embedded in evidence-based research and guided by simulating content. I think that there's a balance always in remaining embedded in research and not drifting to peer support. And research is always evolving and there's always going to be new studies. And so it's always in the back of my head that I've got to remain keep updating the program and maintaining the program, making sure we've got evidence that is up to date. Um positive, I think, is that it feels like free conversation, but it's facilitated by content. So the connections are vital to the program. I mentioned earlier that we introduced alumni events because people wanted to continue to connect with others past the conclusion of the program. So we did a WhatsApp group and an alumni event. What we found with the alumni events is that although everyone said that they wanted to come, we would run them quarterly and we would probably get two people. Um so long term, we weren't we did them for about three years, and then we just decided it we can't continue to do alumni events for only two people. Um, so unfortunately, we we've put that to the side, but people still have the WhatsApp groups that they can use, which is just the members of their own group, to continue to talk and connect with each other. Um and my last point is coaching is essential to translating content into practical action. Um, I don't think the program would be quite the same if we uh finished after the six sessions because I'm not sure it would give people the direction that they need to move forward and put the content into practice. So I think for me, I believe that coaching is really essential in this program. Um that's it for me, really. These are the two papers that we we published, um, and SCIA's uh link to the program as well if you want to see more.
SPEAKER_00:I think you're great. Thank you so much, Emily. Such a big project and so wonderful. And I'm seeing heaps of questions coming into the chat. Um, we've got 15 minutes um to go over them, and I'll just stop sharing the screen. So, opportunity if you wanted to switch um your cameras on, um we can see each other. But um, did anyone want to ask a question? Or Jane, I haven't seen anything that's happening in the chat.
SPEAKER_02:So oh, there's been lots in the chat, and Emily, I've put links to the papers and also FBI Australia in the chat for people. So please do look at the chat, everybody. Um there's uh four questions that we've got, but people are wanted to post more. The first one was Emily um to people of the same age group, and it was it was when your slide about the kind of participants were there and the kind of age group, um, and and the kind of um relationships being important for all, and whether that people of the same age groups meet together um in the in the groups.
SPEAKER_01:We uh so the groups are for any age, and it's funny the way that groups tend to form. Almost, I don't know whether I believe in fate, but almost fate like that we tend to have sometimes groups where it's like all younger women, and then the next time it will be all older men, and I don't know how it works like that, but even if we have a range of ages, we still find that people connect because the the underlying um common ground is that everyone's had a spinal cord injury and everyone's experienced this catastrophic event that has changed their lives, and it doesn't matter whether you're 30 or 60, it's still a common experience, and the the experience has the the conversation it remains, I think.
SPEAKER_02:Yeah, um there was also a question regarding ICD 11, which has um excuse me, a diagnosis of prolonged grief disorder, and whether there are any considerations when you use the term grief in sessions for persons with spinal cord injury was one of the questions.
SPEAKER_01:Not something that we address or look to like or um within the program it's itself. Um so the the session on grief was put together by Skye, the psychologist in the group. Um I think that uh we try to keep it digestible. So although it's uh embedded in evidence, we still acknowledge that the people that are attending these are uh not clinicians and not generally researchers. So the when we're trying to communicate in a layperson's way the the theories of grief and the the change, their kind of internal thought processes, as I mentioned before, of I need to get over this um to more helpful ones, which is probably why we don't bring in more diagnostic tools.
SPEAKER_02:Yes, that's that's helpful, thank you. And um I had a question um around how how long after injury might people attend the groups. Um there was another question around um is it um kind of in inpatient or what challenges do people have um transitioning to the community? So a bit about kind of timing that might that would be helpful think helpful?
SPEAKER_01:Yeah, so we we typically say that we want people to be at least one year post-injury. Um I think as I mentioned in the presentation, um while people are in rehab, they typically have access to psychologists, counselors, and other support. And we think it's important that they focus on that time in rehab and their recovery in rehab and on getting home, etc. Once they've home and they've transitioned, perhaps they're starting to question what they're going to do next. That is the point in which we would say, right, join the program. That being said, we would always take it on a case-by-case basis. Is that if there's someone in rehab and they really, really want to do it, then okay, why not? More than welcome. Um, but timing-wise, yes, we typically say one year post, and it can be you we've had people that are a year post, we've had, I think, you know, 40 years post-injury. Um, we have it's really open to anyone in the community that is struggling with feelings of isolation, wanting to connect, what is a purpose? Um, and so for the for the gentleman that was 40 years post, he had just retired. And I think he found a lot of meaning in his work. And so once he retired, he was questioning, well, what is my mean? Like, what am I gonna do? What is my meaning? I have this injury, I'm physically uh unable to do a lot of the things that perhaps I would have seen myself doing as a retired person. My coping strategy almost was just work because I could do that, and that's that gives me purpose. So now what am I gonna do?
SPEAKER_02:Thank you. Um and another question is whether you just include people in the program who um have sustained an injury from an um an event, an accident, or also kind of um diseases and um kind of non-traumatic, although I don't like the term non-traumatic um causes.
SPEAKER_01:Yeah, we've had non-traumatic causes. We also because SCIA not only do support people with spinal card injuries but other neurological injuries, we've had people with MS joint, we've had um a strokes, um, so and then there has been a gentleman with a brain injury, but again, that's case by case. We would just look at well, are they able to participate in the group effectively? And and um yeah, so it's not not just spinal cord injury, we do work at the neurological conditions.
SPEAKER_02:Thank you. And I think the final one for me is around how I mean it's a fabulous program, brilliant group. You know, I'm just wondering how people can whether there's um much more demand than there are kind of groups available to meet that demand, or how people can connect with it or can kind of come in to the to the groups.
SPEAKER_01:Yeah, so we advertise our groups like all year round. We typically set two dates uh across the year, and as I said, we would just um we have to work hard, yes, to to make sure that we're advertising to get the numbers to run the groups. Um but in terms of I mean, spinal cord injury, there's not a huge population. Um there's not an endless amount of people that will want to do this group. Um, but generally we have enough interest to be able to run these two groups per year. I wouldn't think we could do any more than two groups, we just wouldn't have the interest. Um, but there's enough interest for the for that. Emily, thank you.
SPEAKER_02:Yeah, yeah, no, it's brilliant. Thank you very much. That's really, really helpful. Does we've got a few minutes left, whether anybody would like to ask Emily a question on camera?
SPEAKER_00:I've got a question, but um, if if no one else does, uh Emily, I was curious whether you think the program or the course would be just as successful if it was delivered in parts. So um, because each of those um sessions that you described are really valuable. And I wonder for some people the thought of committing to the entire program might be overwhelming, but if they could be engaged in just one part of it, then that might be a stepping stone for them to then do another part, or um, for those that may not be as engaged.
SPEAKER_01:Yeah, I think that the content can be like digested in all its separate parts. I think that the the benefit of our program or the unique part of our program is this connection that develops. And I talked at the beginning about how post-traumatic growth requires this process of cognitive rumination, and we find that the program and the conversations we have help people go through that process of um reforming some of their beliefs about themselves. So whilst you could just sit on in on one session and just don't know whether you would get the same impact from being in this group for six weeks essentially, forming connections, opening up, you know, you're there and participants almost support themselves. Like I sometimes I feel I don't need to be there because they're providing support to each other. And I think that is what's meaningful in in telling their story, their they're helping someone else and then giving advice. Um, so yeah, I'm not sure it would have quite the same effect if you only chose to do one session.
SPEAKER_00:Now that makes sense. Thank you. And maybe just fine.
SPEAKER_02:Oh sorry, sorry, I was just sorry, what time was we were just doing time. Somebody's got their hand up, uh Emily Time.
SPEAKER_03:Yeah. Yeah, thank you. Thank you for your presentation. Brilliant, absolutely. I was just wondering why your whole program is based on uh the um postformatic growth, and then you do your quantitative uh assessment, and postformatic growth is not in there. I was wondering why not.
SPEAKER_01:So I have to say the measures were all like the measures were all organized before I joined the program. So I can't speak to why Phil Shane decided not to include a measure of post-traumatic growth in their assessments. Um, you would have to ask them. I came in at a little bit of a later stage uh during the running of the pilots. But if I was to do the program again, I would also look at some more positive um measures as well, and look at well, I don't know. I I like to focus sometimes on how interventions improves people in a positive way. So maybe you'd look at um self-efficacy or yeah, I think I would do different measures now if I if I was to go back. Um I'm sorry that doesn't answer your question in terms of why I wasn't involved in that conversation. But yeah, I think I would do it differently now.
SPEAKER_03:Thank you.
SPEAKER_00:Thanks, Emily. Uh okay, just to to to wrap up on this this session, um, we would really love your uh feedback. And um sorry, just get to the screen. Um so to finish up on, we'd really love your feedback on today's session. So if you have an opportunity to quickly scan that QR code, the second one, um, that would be fantastic. Just as a reminder, if you would like to stay in touch with the the webinars and be on our mailing list, um, the link is in the chat, but also the first QR code will take you to that. And as I mentioned also earlier, that Dr. Danny Brent will be delivering next year's webinar in the first half of the year, so please keep an eye out for that information. But thank you again so much, Emily, for um today's talk. We really appreciate it, and thank you everyone who's joined in. Um, this session has been recorded, so it will be available to those that have registered but haven't been able to attend. Um, but likewise, if you wanted to go back to it and look at any of those resources that Emily spoke about, you'll be able to see it in the recording. Um, so have a good day or evening wherever you are, and we hope to see you at next year's webinar. Thank you.