We See You!
Chief Clinical Officer at Gateway Foundation
Men, young men in particular, make up the largest substance using demographic. Jim Scarpace talks about the baggage that comes with the cultural expectation of excessive use and how to break through the isolation that comes with the disease of Substance Use Disorders. Jim Scarpace is the Chief Clinical Officer at Gateway Foundation, one of the nation’s largest providers of behavioral health services for clients diagnosed with co-occurring mental health disorders. Jim has over 25 years in administration, operations, and the treatment of mental health, substance use disorders, and criminal justice programs. He is also an assistant professor of Clinical Psychology at Benedictine University. Gateway Foundation offers a full continuum of care across a wide range of clinical settings and can be contacted at their 24-hour hotline 855-925-GATE (4283) or at www.gatewayfoundation.org.
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Mike: Welcome, everybody. This is Avoiding the Addiction Affliction, brought to you by Westwords Consulting and the Kenosha County Substance Abuse Coalition. As always, I'm Mike McGowan.
Mike: We've heard numerous times here about the need for additional substance abuse resources for specific populations. We've chatted about treatment specific programs for different demographic groups in our population, and today we're going to continue that discussion about treatment for the largest demographic group experiencing substance use disorders... men.
Mike: My guest today is Jim Scarpace, the Chief Clinical Officer at Gateway Foundation, one of the nation's largest providers of behavioral health services for clients diagnosed with co occurring mental health disorders. Jim has over 25 years in administration, operations, the treatment of mental health and substance use disorders, and criminal justice programs.
Mike: He's also an assistant professor of clinical psychology at Benedictine University.
Mike: Welcome, Jim. Thanks for being here.
Jim: Thanks, Mike. Thanks for having me.
Mike: You know, we're going to talk about a lot of things, a variety of substance use and mental health issues, but I want to start with your program geared towards helping men with substance use disorders.
Mike: Tell me about the program for men.
Jim: Sure, I'd be happy to. So, yeah, Gateway Foundation has focused on specialized program for men since our inception 55 years ago. It's been a long time we've been, you know, doing this and really trying to reach out and help those who are struggling with both substance use disorders and co occurring disorders, and the men's programs really start to focus on issues that are very specific to men, not only in terms of being able to manage their substance use disorder and achieve recovery, but also deal with the things that, you know, men have to deal with in society and in the community that are sometimes difficult to deal with.
Jim: And the first and foremost piece is really breaking down the stigma associated with substance use disorder. Because for a lot of men, there's a pride issue, but under that pride issue is a fear issue, a fear of, I should be able to manage this, I should be stronger. I should be able to stop this on my own.
Jim: What is wrong with me? And that, that fear associated with that sense of pride really can lead to isolation. And for a man who's struggling with a substance use disorder, a lot of times for anyone, but especially for that demographic, it can feel like this is who I am. And when it feels like this is who I am, that's really hard to make changes.
Jim: So one of the things that's important to us in our men's program is that we start off with one of the first pillars of what I call recovery which is disease education and really understanding what this illness is. And I always give the example to the guys when I was a clinician and an executive director in some of those programs years ago. That, you know, if you had cancer and the doctor said, Hey, look, this is what's happening.
Jim: We know that there's cancer. We know it's in early stages. We know it's treatable. Here's the treatment plan and the recommendations I have for you, whether that be chemotherapy, whether that be some kind of medication assisted therapy, whether that be some kind of other treatment methodology or recommendation.
Jim: Most men would not say, thanks doc. No, I can handle it on my own. I'll be able to get this under control. I don't need any help. They wouldn't do that. But because of the stigmas associated with substance use disorder, many men will hide those problems and when they are confronted with it, will be in denial, not because they don't know that they're struggling, they know they're struggling, but because of that pride issue of, I should be able to handle this, I should be stronger.
Jim: So a big pillar for us initially is that disease education component and teaching them what we've known since the 1950s, that this is a disease of the brain, that it really affects the physiology of the brain, and therefore because the brain has impact on behaviors, also affects behaviors, makes it difficult to not only discontinue use.
Jim: But usually leads to increased use over time without treatment. So a lot of our initial work on the men's program is around that and helping them understand the illness.
Mike: Well, think of all the messages that men get socially whether it's ads on TV or from their peer groups they're culturally targeted and inundated about messages regarding, well, a variety of things using gambling.
Mike: I mean, turn on any sport event so you can see why. And so there is a sobriety stigma.
Jim: It really is. And unfortunately, in our popular culture although I've seen a little bit of a reduction in it, there's still a lot of glamorization of substance use, especially alcohol use. And, you know, we have some specialized programs at Gateway that focus just on men's issues as well as alcohol use disorder specific to men.
Jim: And that's a really difficult one because if you are in that population where you have an alcohol use disorder. And let's say your family and your friends are able to manage and monitor their alcohol use to the point where it doesn't create the same difficulties or challenges or dysfunction it's causing for you.
Jim: It's really hard to come forward and talk about that because as you said, any sporting event, Any pop culture movie or what's the word I'm looking for? Netflix that holds me a streaming kind of thing that right now it's everywhere. And it's really hard when you're looking at that as a man to say, people are able to do this and not have the negative consequences that I'm experiencing.
Jim: What's wrong with me? Why am I not strong enough? And so again, it's really breaking down those misconceptions and helping people understand what this is. And most importantly, that it can be treated because once people achieve recovery and understand what recovery is about and that it's possible through a combination of the treatment programs and services, we have at Gateway.
Jim: It's kind of like hearing that message when you have cancer that you're in remission. There's a sense of relief like, Oh my gosh, I can do this. This is not who I am because for a lot of men, you know, the disease of substance use disorder really overlaps into who they believe they are and they forget who they are as a result of that.
Jim: And one of the messages at Gateway is we see you, you, Y capital Y O U. You are not your substance use disorder. Your brothers, your dads, your uncles, your sons, you're successful in the community. You have. And that substance use disorder tends to mask all that and take it away. And so we really want to do a lot of work in helping them understand that as an initial foundation, even before we start some of the treatment approaches that we know can be helpful in their recovery.
Mike: Well, let's talk for a minute about, and the reason I wanted you to be on here to begin with is the largest demographic group, and that's young men. Right? That group 18 to 25, we've seen that explode again. And, you know, when I see an 18 to 25 year old with substance use disorders, I assume they didn't just start yesterday.
Mike: So, you know, and combining with social media and COVID, you have a real, oh, lack of social and emotional skills, which are already difficult for men.
Jim: Absolutely. And unfortunately, substance use disorder is a disease of isolation. You know, I I've always said, you know, it's a physiological disease that affects the brain.
Jim: It's a psychological disease that affects your thinking and behavior, and it's a social disease. It affects your interactions and your relationships, and it really causes you to isolate from those protective factors or those strengths or family members or friends that might be able to help you. , get the support you need, but you don't talk about it because you know it's embarrassing or you're fearful of what they will think of you, and especially for young men during this COVID experience.
Jim: Where we've had to physically distance ourselves over the last few years, I know we're coming out of that and it's starting to spike a little again in some places, but with that physical distancing came emotional and social isolation. And when you have a substance use disorder, that's one of the worst things that could happen to you is you're socially isolated from support systems or from strength family members that could be strength to you in the recovery process. And the other thing for young men that I think is important and you said this well, is it just doesn't you don't wake up one day and this is happening and you didn't see it coming. A lot of times mental health issues like depression and anxiety start off with being treated by maybe an adolescent or a young man with alcohol or drugs as a way to self medicate those symptoms and it provides a temporary band aid initially. But it isn't very long before you have two separate but related problems on your hands. And for that young man, it could be, I started self medicating my depression with alcohol. I had one young man that told me once, if they could put alcohol in a pill, he'd never have anxiety again because he was using alcohol to self medicate his anxiety.
Jim: And pretty soon he had what we call the co occurring disorder, an anxiety disorder and an alcohol use disorder that, although separate in terms of their foundations were very much interconnected in a lot of ways and needed to be treated together. So for our young men, especially coming into the programs, it's a lot of work on what we call ESP.
Jim: And what I mean by ESP is not extrasensory perception. It stands for educate, skill build and practice. That we need to help them understand the relationship between their mental health disorders and their substance use disorders. Another piece we haven't talked about. Which was a big part of COVID as well as trauma. You know, the trauma experience of either, whether it be during the COVID period of maybe either losing a family member or having people that you care about being sick or you yourself are sick.
Jim: But outside of that, trauma experiences that young men may have experienced as an adolescent or a child also need to be worked through because those are triggers to the substance use disorder and they're really all interrelated. So a lot of our work at Gateway is not just about teaching, but then once I understand what are some of the triggers to my substance use disorder and what are some of the things I need to work on alongside it.
Jim: What do I do about it? And that's where the skill building comes in and learning some of the ways to manage that psychological component of addiction and, you know, understanding distorted thinking and high risk situations and triggers and all those pieces.
Mike: Well, Jim, there's also a stigma around that component, I mean, to connect emotionally. You mentioned fear before, and I'll throw shame in there as well, you know, the stigma for, you know, you and I are at least in the same ballpark, it looks like, right?
Mike: Deal with it, rub some dirt on it, you know, take care of it, bury it. And in other words, well, that's the opposite of what recovery is.
Jim: Absolutely. And it kind of goes against our nature. Our natural tendency as men to we should just be able to handle this. We need to deal with it. We need to figure out a way to put it aside and take care of our families or, you know, address more important priorities, not realizing that that issue that we're burying or setting aside or not dealing with is related to all those things.
Jim: And unfortunately, with substance use disorder, we know it gets progressively worse, not better over time. And the potential, depending on the substance and the frequency of use, the potential damage to the brain, and some of our abilities to have, be able to solve problems, and some of the more of the executive or frontal lobe functions of the brain can be severely impacted if we don't get treatment as soon as possible.
Jim: And so the good news for young men is they're usually early on in the struggles with their substance use disorder. So achieving, recovering, maintaining it is actually much better in terms of odds for them than someone who's been using for 20, 30, 40 years. And I've seen many of those individuals recover as well.
Jim: It's just more challenging.
Mike: How do you see in your treatment program, the generations interacting?
Jim: You know, it's interesting because. Especially over, I'd say, the last five or 10 years because of social media and just the way people interact now via text message and through virtual platforms like this versus, you know, individuals who maybe were not as acclimated or inclined to be on those types of platforms or use those types of technology, it can be a struggle.
Jim: So we've had to adapt some of our training programs and our treatment programs at Gateway to meet the needs of the population we're serving. So one of the things we implemented here, for example, a few years ago, was called a Cared For app. And it's an app we use in outpatient that allows patients to not only track their progress, but be able to report high risk situations or triggers via text in this app that's really allowed them to communicate with their therapist in different ways than they normally would.
Jim: In a traditional outpatient setting, they're still doing those services, of course, but in addition, they have this new technology tool. That's not for everybody, right? Are some of our individuals that are not as comfortable with that technology may not use it, but we really need to.
Jim: And one of the things we realized we need to do is be as innovative as possible in meeting the clients and or patients where they were. And really trying to address the needs of the younger generations who are much more dependent. or comfortable with technology as a way to communicate.
Mike: I see. You know, we've had people on here who have a social network following, and it's almost like their support group are people they've never met, as opposed to, hey, go down to the church in the basement and do the 12 step meeting.
Mike: What do you encourage post treatment for that kind of recovery?
Jim: Well, that's a good question. I think that, again, you know, if we can get people connected to some kind of community support, whether it be 12 step, there's some new programs out there now called Recovery Dharma. I don't know if you've heard of those, but they have a mindfulness component to them and they're very much in line with some of the treatment approaches that clients may learn when in treatment with Gateway, for example, like recognizing high risk situations, utilizing mindfulness to identify where you are, where you could be and where you need to be.
Jim: What's most important is that people feel connected to whatever that community resources that we're going to connect them to when they leave formal treatment. Cause I've always said to both staff and clients that formal treatment is really the beginning of the process.
Jim: We establish a foundation of recovery for individuals. But we need to make sure they're linked to the right resources when they leave our programs to maintain that recovery because recovery is a lifelong journey. It's not as though... I have an alcohol use disorder, for example, and I went through treatment at Gateway and I've been successful and it's really helped me.
Jim: And now, you know, a year later, I'm going to go back to drinking and everything will be fine. We know that's not how it works. We know that's not what the science has said, and we know that's not going to be possible. So it's really important that those individuals are connected to community supports that they feel comfortable with, that they're going to maintain contact with.
Jim: And for some individuals, that is 12 step. And of course. The traditional 12 step meetings work for a lot of people. And at Gateway, we want to support those programs, but we also want to provide alternatives if that's not going to be a good fit for you based on either your age. Or where you live, or what you think will work for you.
Mike: I was actually going to ask you the question, especially for young people. Because I got it all the time when I worked with them. You know, to say, yeah, this is a progressive chronic disease, you got it. Let's not drink. And the answer would be, for how long?
Jim: Right, right.
Mike: That's harder when you're 22 than when you're 52, I think.
Jim: It is, it is. And it's hard to have those conversations. And from a harm reduction standpoint, do we recognize that someone leaving treatment may not be able to maintain abstinence immediately? I think we recognize that that could, that that could be a long term goal for them and a road that they need to be on, but that there's going to be some deviations from that road and those deviations may include return to use at times.
Jim: And what's most important is that they feel connected enough and trust the treatment center or the programs are working in enough to have those conversations. And I've always said that to staff and clients is. Our job is not to prevent people from returning to use because we can't control 100 percent whether or not they do that.
Jim: We can provide a roadmap to keep them from doing that and give them skills and education and medication and knowledge and services and supports to really try to make it as likely as possible they stay in recovery. But at the end of the day, if that falls through for some reason for them because of a choice they made or a situation they end up in.
Jim: And they return to use. Do they trust you enough to have that conversation? Do they feel supported enough to be able to come back to you and say, I, you know, this happened, I need to figure out how to get back to where I was because that's really what treatment's about is not only providing them with the supports and skills to be successful in recovery, but should there be a relapse, do they feel like they can come back and have that conversation with their counselor, with their therapist, And so building those relationships is really important to us.
Jim: We use something called motivational interviewing. All our therapists are trained in it is really making sure we're meeting people where they're at and helping them understand that the road to recovery is not always a straight line for everyone.
Mike: Well, you know, that's we're, we just circled back for me to the same issue again, which is, okay, I got this.
Mike: And to relapse or to stumble, there's that pride thing again, right? And so it's the relationship plus it's overcoming, right? That sense of I failed. I should never fail. And, you know, that's also a tough conversation.
Jim: And the one piece we haven't talked about that makes it even tougher for some people is family members.
Mike: I was just going to ask that, yeah.
Jim: I've had family members who said to me, I've had a couple different experiences with this on both sides of the continuum, if you will. A family member who said, 'cause for us at Gateway family involvement is a big part of the treatment process. We wanna make sure family members become experts in their loved one's recovery plan because they're the ones that are gonna be supporting them in either taking medication if that's necessary for depression or anxiety or medication assisted treatment, depending on their substance use disorder.
Jim: Or making sure they're following through on the support plan that's in place, making sure they're attending their outpatient programming or services when they leave residential, if they're in residential with us for 28 or 30 days. Making sure that the ancillary support systems are there to help them in their recovery journey.
Jim: And when you have a family member who either doesn't believe this is a disease, or I had a family member once I say, after I said all that to them, Yeah, I'm not attending any of these family education groups because if they loved me, they would have stopped a long time ago. And that's a family member who's angry, who's hurt.
Jim: Do they have right to be angry and hurt? Of course they do. But it's someone who doesn't understand what their loved one is going through in terms of the substance use disorder. If they had a heart, if they had heart disease or cancer, they wouldn't be like, if you loved me, you wouldn't have, you know, developed this illness.
Jim: You would have done something about it to stop it. But with substance use, because of that stigma, because it's a disease of the brain and it looks behavioral, it's really easy for family members to kind of fall in that bucket and say things like that. On the flip side, I've had family members, I still remember this, and this was years and years ago, I had a young man in treatment with us, three near death overdoses on heroin.
Jim: Was finally agreeing to come into treatment, which was great, we were able to get him into our men's program. And, you know, after a few days in there as it starts getting uncomfortable, right? Because you feel that need to use everything in your brain is telling you as the opiates are coming out of your system, you need to get opiates back in our system again, because the brain has developed not only a tolerance, but, and it has adjusted to that opiate being in there in their body in and impacting their brain. And he was like three days into treatment and his mom called me and said, I'm coming to get Tommy. He learned his lesson. [inaudible] a mom who doesn't love Tommy. And I'm just making up a name.
Jim: Of course, of course not. She loved him, but. She believed that this was a choice Tommy was making. And now that he's had a consequence, he's going to no longer use again, someone who just didn't understand the illness. So one of the things we really try to make an effort to do early on is have as many conversations with family and support that are going to be part of the treatment process with the person as possible.
Mike: Well, and I've also found that there's a lag, so, you know, there's a walking on eggshells for a while, and then the person in treatment or recovery starts to feel pretty good and gets their feet underneath them, and then a couple months later, the family members go, okay, now it's safe to blast you for what I've put up with, (chuckle) you know, that's it, you know, and now they're out of your facility, though.
Mike: So there's a need for continued work and to let them know upfront. Right? To predict what's going to happen down the road.
Jim: Right. And one of the things we do a lot of work on in our recovery support education groups, where it's where family and friends and loved ones who are part of the recovery journey with the person are involved is we talk about that brain healing.
Jim: And the reality is at minimum, it takes about a year with the substance out of a person's system for the brain to redevelop patterns and ways of not only the neurotransmitters chemically to be back in balance, but the way the person thinks to be in line with the recovery process and really doing a lot of work with families to understand, even if during that year, someone might return to use and come to them and say, Hey, I need help again. I was in this situation, got overwhelmed or wasn't expecting this exposure to the substance and I used. To not have the family members feel like all that work was for nothing.
Jim: We did all that work with you in treatment. You went to treatment, it was for nothing. You didn't learn anything.
Jim: Doing a lot of that upfront work to prepare them. Of course, we don't want people to return to use or relapse, but should they? Families understand, yes, everything they learned is still there. Yes, they still have the skills. They just need to get back on track, and you need to get them either back into services with Gateway or into a program or if nothing else helps support them in whatever they need to get back on the recovery road and it's hard for some families.
Mike: It is. I even had therapists back in the day. And even now I hear it too. It's like, well you know, now they can't go back in their "treatment smart". And I'm like, and what's wrong with that, that you now know your disease better.
Jim: Right. It's interesting how the field over the years has changed and adapted and some places have not because that is an old school way of thinking.
Jim: I mean, it would almost be like, you know, with any again, any other medical condition, if you had a relapse or you were diabetic and you know, you put yourself on a special diet and then you went back to eating different foods that you shouldn't have in your blood sugar start to spike and you go to your doctor and he's like, you know what to do.
Jim: I'm not giving you any more medication or insulin. You just, you should have, you shouldn't have done that.
Mike: Right, right.
Jim: They wouldn't do that. But here it's really easy for people to look at it that way. And there was a time in some outpatient centers where If you relapsed while you were an outpatient, you couldn't no longer be an outpatient anymore.
Jim: You had, you were kicked out, but that's really an old school way of thinking. And if you recognize that the journey to for recovery is a process that is not always a straight line, you should be prepared to help that individual who drifts off that recovery road, get back on it versus punishing them or penalizing them for returning to use.
Mike: Well, now if we can only get the payers on the same side, right?
Mike: That's another podcast.
Jim: Oh, right, right, right. Yeah. No, I mean, sometimes you do have the, although I will say that in Illinois, some of the payers, especially with really looking at ASAM criteria now when they're making decisions have been more open to even patients or clients who've been in treatment before getting that level of care, that service again, recognizing, okay, here's the piece we missed last time.
Jim: They're now back. As long as we're going to be able to address that piece in a different way, supporting it by approving the day. So we have seen a little bit of a, of moving in the right direction. I would say with payers in that way.
Mike: I want to give you a couple last questions. One is one I hear from counselors a lot.
Mike: Going back to young men, what do you say to them if they go, Okay, I get it. These opiates, they're terrible, man. I can't handle them. So I'm just going to smoke weed. I'm just going to drink. And you know, that's something that you're going to hear if you're working with people.
Jim: Yeah. And that's a tricky conversation because you want to keep them engaged.
Jim: And the good news is they're reducing their opiate use, right. Or they're committed to that. So that's a positive. I don't want to diminish that and no way in that conversation, do I want to create a scenario where I come out guns blazing, saying, no, you need to stop use of everything now, this is all related and connected. How your brain is impacted by opiate use isn't any different than how your brain will be impacted by the alcohol or marijuana when it comes to the addiction pathway in the brain. And that's all true. Research supports, that is all true, but my conversation with that client, especially that young man has to be different and it has to be about first and foremost, praising and commending their decision to reduce their opiate use and helping them understand the benefits of making that decision.
Jim: And then starting to talk about some of the risks associated with other substances in terms of that addiction pathway, but in a way to say. You know, I think one of the things that's really important to think about should you decide to go down this road is the negative consequences or potential risks associated with using marijuana or using alcohol as an alternative to opiates because those things do impact the brain in a similar way and what are some of the things you need to look for should you choose to make that decision versus if you make that decision, your life is over, you're making a mistake, because then the defense mechanisms go up, the shields go up. And our goal really, from a harm reduction standpoint, right, is to not only improve quality of life, but save lives, and if I have to work with a client who said, I'm giving up opiates, I'm not going to use heroin anymore, I recognize the risk associated with it, I've learned both from a skill based perspective as well as being on medications to manage my depression, how those are related. But I think I may still use marijuana at times, especially when I get anxious, we'll work with that, you know, because there's, we can, I'd rather work with that person who's making that decision than say, nope, until you choose to not use any substances, we can't help you.
Jim: And then they're out there in the community with no supports when, you know, maybe at some point, you know, meeting them where they are allows us to get them down the road to stop using marijuana too, but we're not going to even have that opportunity if we don't build that relationship.
Mike: Well, and you just led me into my little walk off for you.
Mike: You've been doing this a long time in the criminal justice system and the treatment system. What is it like to see the light go on?
Jim: Yeah. You know, it's interesting. A few years ago, we did this thing at Gateway called Illuminating Recovery and really helping people understand what recovery is and most importantly, what substance use disorder is.
Jim: And I've done a lot of work with judges and state's attorneys and probation officers around changing language, talking differently to individuals that they're working with in the court system that might have a substance use disorder. We've seen specialized drug courts come out of some of those programs that have really helped a lot of people in the different counties, but I, the change process is a slow one sometimes, but when you see someone Make that change and recognize the connection.
Jim: You know, it's amazing. And when you see someone understand what recovery is, and recovery is more than just sobriety, right? Recovery is a whole lifestyle choice in terms of supports, coping skills, strategies where you live, who you interact with. And I still remember, this will be a story that will stick with me my whole life, is I was interviewing a counselor a while back.
Jim: An excellent, you know, went back to get a C. A. D. C. Little bit later in life and great, great interview. And he offering him a position with us. And he said, you don't remember me, do you? And I didn't. And he said, 10 years ago, I was here and I'd given up. My wife was going to divorce me. I was struggling with alcohol.
Jim: I was losing custody of my kids. I felt like there was no chance for me. And you came down and back then, and even, you know, throughout my time at Gateway I did something called the community issues group, where as director, I would go down and just talk to the clients about what treatments about what substance use disorder is, that it's a disease of the brain.
Jim: It's not a moral failing. He said, and you did that spiel and I did that every week for 10 years. So I didn't remember him. That was a long time ago for me, but for him, he said, that was the first time in my whole life. That I felt like this wasn't who I was. And most importantly, that there was an opportunity to be who I wanted to be.
Jim: And that this illness doesn't, this disease, this addiction to alcohol doesn't define me. And he said, I finished a program there, I went back to school, I repaired the relationship with my wife, and here I am 10 years later wanting to help other people who are sitting in that chair I was sitting in. That, when that light goes on and the things you can do with it, that's I think a great example of how amazing it could be.
Mike: That is great. That is awesome.
Mike: Jim, thank you so much for taking time out of your day to talk about this. It's such a huge issue. It was so easy for us to focus on a lot of populations and all of a sudden I said about 100 into these. I went, Hey, we haven't talked about men. They're just the largest group, so.
Jim: Well, and the one thing I will leave you with is for any men listening to this podcast, if you're feeling like I could maybe use help, I'm not sure. If I need help or not reach out because at the end of the day if you don't need the help the gateway can provide great, but should you need it? It can change things for you drastically in a short period of time. And we have a 24 hour hotline, 855 925 GATE or 855 925 4283. And then if you just want to get information, our website www.gatewayfoundation.org has a lot of information there so you could start to explore this idea of Is treatment right for me?
Jim: What would it look like? And how can it help?
Mike: And for those of you listening, you know that we're going to put both the number and the website at the tag end of this podcast. So please take advantage of it. And if you can, listen in next week. And until next week stay safe and take a risk to open the window.
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