[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. [DR. CRISTINA] Well, hello everyone. Thank you for all of you loyal and consistent listeners and subscribers to the show. I sometimes record the show and I have no idea who is out there listening and what you're thinking so it really does mean a lot to me when you rate and review and subscribe to the show, like on Apple Podcasts. I also really appreciate when you comment on my social media posts or send me a question or personal message about the show. So I got to thinking the other day that, because some of you do take the time to reach out, that I want to acknowledge you. Now, I don't do this show because I'm making any money or profit off of it. I really just do it solely for anyone out there who's listening, because I'm hoping that I can spread the correct information and awareness about eating disorders and dispel any myths that are contributing to the toxic diet culture that's out there and really just to help anyone out there who's struggling so you're not alone and really to give you the hope that you can absolutely recover. So if you are here listening, which absolutely means the world to me, I want you to know that I want to know what you want and need to hear on here, because after all, this podcast really is for you. So message me. Let me know what you think of the show. Ask me questions. I'm going to start each show with your comments and your questions. So if you have something on your mind, let me know. I found out that there's this nifty new voice message website, and I'm going to leave the link here on the show notes, and I want to message mention it here. It's www.speakpipe.com/splashbehindthebite. You can go on there and you can actually voice record a message for me and just leave your question, leave your comments. Like I said, I want to hear what you have to say, and I'm going to start mentioning these things on the show. So this is exciting for me to start doing that. That being said, we are here today, and I don't know about you guys, but if someone would've told me three years ago that I would be sitting here today living my day-to-day life the way that I am, I probably would've looked at them like they had 10 heads. You know what, maybe your life hasn't changed as dramatically as mine has, but then again, that might be because I work in a field that has forever transformed as a result of the pandemic. I know that is the case for so many of us who are mental health providers. Now that there's been some time since the start of the pandemic, I have with us today a guest who is here to reflect on and discuss more about how mental health awareness and treatment has been affected and more specifically, get into a discussion about eating disorders in the pandemic. In her role as Chief Clinical Officer for Alsana, Heather Russo is responsible for nurturing the growth and success of their clinical treatment teams and maintaining the integrity and efficacy of their adaptive care models therapeutic dimension. Heather has served as a clinician and clinical leader in eating disorder treatment for 15 years. Most recently before joining Alsana in her in 2020, Heather served as the regional assistant vice president of a multi-site national eating disorder treatment provider, where she focused on clinical consistency and the implementation of evidence-based practices. Heather has been a chair of several well-known associations, including the International Association of Eating Disorder Professionals in the Los Angeles chapter, and between work, school and three kids at home, including four-year-old twins, Heather says she doesn't have an abundance of free time, but she absolutely loves what she does. Well, Heather, welcome to the show. [HEATHER RUSSO] Thank you so much for having me. I'm excited to have this conversation with you. [DR. CRISTINA] I am too. I have not had this topic on and I know it's a big one so let's just get into it. What have you seen during the pandemic and I guess even now at Alsana with eating disorders or just in general? What's your take on things? [HEATHER] What do we make of all this? I think it's interesting when I take sort of a macro look and look back, I think about almost sort of pre-Covid and where we were as a treatment industry and how ready were we to begin with. I think that there were there were a couple companies that were offering virtual treatment for eating disorders, several companies, I think had some online support for individuals that were struggling, whether they be sort of community support groups or alumni groups, but there was not a proliferation of virtual eating disorder services from the provider end going into the pandemic. So we sort of had this convergence of a lot of companies probably having initial conversations around what would a virtual program look like, beginning to flush all that out and March whatever, 17th of 2020, really needing to figure it out. So I sort of think about when the pandemic hit. There were folks who were mid-treatment. There are folks that were nearing the end of their treatment or that were sort of an early recovery post-treatment, and then folks that were cruising along just fine and then were hit with all of the stressors and all of the dynamics that the pandemic brought. The clinical picture looks really different for each of those kinds of groups of folks. The ones that we probably you and I both as providers during all of this, there was the sort of initial, I don't know, surprise for all of us even as clinicians and providers of how do we manage to support the folks that we are wanting to support while we're also struggling through ourselves and our families or dealing with new patterns and rituals and all of the uncertainty and the stress that all of that brought. So I think in all honesty, I think that there are probably a lot of sort of outcomes of what we went through, even in 2020 that we're still not going to fully appreciate until even later than now. We're still sort of sorting through all of this yes. I think that there's a lot to like parse out there, but certainly we're still looking at the impact of all of this from the both the provider side and the client side. [DR. CRISTINA] So, I mean, you bring up so many interesting points here that we could delve into, but I'm just curious when that all hit patients that were being seen obviously in different levels of care in person, were they forced to no longer be seen in person because of the pandemic and because of maybe some restrictions that were placed on people being around each other, or what happened there? [HEATHER] I feel really proud of the way Alsana specifically handled it, which is that we didn't skip a beat. So we got plexiglass and masks and sanitizer, and we distanced, and we never closed our doors for our brick and mortar programs. No, I know not every treatment program or treatment provider had that luxury. We had the infrastructure to be able to do that and we feel really, really grateful for that. So we've operated brick and mortar through the whole pandemic and that's been a heavy lift. Also, we've learned things along the way as all of us have, what works, what doesn't work, what's practical and what's not, how do you quarantine folks, how do you, just all of the, how do you support somebody while they're in quarantine? I mean, I don't know if you've had to quarantine, but I've had to, and it is pretty brutal. I'm a relatively well-adjusted adult, pretty stable with good support and all of that. So yes, there's just been a lot of learning that Alsana has done, and certainly all of us in the field have done, but we were able to both keep our in-house brick and mortar programs running and also develop virtually overnight a virtual PHP and IO P program. We were able to do that in in lockstep with each other so we were sort of battening down the hatches in terms of protocols and whatnot for our Covid protocols in-house and then also developing a national virtual treatment program, which was a really fun, creative challenge. That was really hard. [DR. CRISTINA] Wow, hard, yes. A whole new way of thinking about providing treatment, right? [HEATHER] I mean, as a therapist, I was always trained about boundaries, boundaries, boundaries and here we are now doing treatment in somebody's bedroom and what like be sort of practicalities that you want to be, you want to show up for folks and be helpful and create a program that is going to best support them. Whether they are afraid to be in brick-and-mortar programs, they can't travel or they're nervous to travel or they're having to quarantine and so not able to. So it's just, there are all these different stresses on our clients, and we really wanted to meet clients where they were at. That's a sort of the core Alsana sort of foundational philosophy that we really do try to meet our clients where they're at and so that meant sometimes in their bedrooms and sometimes at their family dining room with cats walking by and whatnot. But also afforded us the opportunity to do some really cool interventions that were, that we wouldn't have been able to do in an in-person program. So that part has been really cool. The thing that gives me a lot of joy is both helping to sustain and grow access to care, but also being able to do it in folks' real-life world and going into the kitchen with them on their laptop and looking in the cabinet with them and walking through what is it like to look at this box of cereal right now, like, let's hold it up, this is your box of cereal, let's talk about it. So those have been really cool, I think yes, opportunities, silver linings, although there haven't been many, but those are some. [DR. CRISTINA] I'm curious, like, I mean, that alone, just being able to do different types of things that you can't do when they're at Alsana. Were there other things that you found that you were surprised that helped or worked that you hadn't done before? [HEATHER] One of the other silver linings was the barrier to access support of others and family members. The reluctance and the avoidance that typically shows up with clients not wanting to involve supportive others that became a non-issue because if mom or dad or spouse or roommate is in the next room over, we're not having to deal with the back and forth and the avoidance and all of that, and we can strike while iron is hot and the client is willing in that moment to involve somebody else as we all want them to do. We're able to capture that motivation in that moment, rather than that sort of back and forth of scheduling emails and all of that stuff where, where voids can tend to crop up a little bit and the process would get halted. So that part of things, I think has also been a pretty cool silver lining up the whole thing. [DR. CRISTINA] I had a different experience because I was, I'm in private practice and not at a facility. But I freaked out. Too, because I had only been trained to do in-person therapy. So I couldn't see the person except for the shoulders up. With the eating disorders, that was really scary for me like, I'm not going to see their whole person. I can't see their body language, I can't see if they're shaking, I can't see so many things about what's going on in the person I'm working with. So I'm wondering for you, was that something that went through your mind as well? [HEATHER] Oh, well, the practicalities of it too, Cristina. So we were, we learned nearly all things the hard way. I'm going to be really honest about that. We learned the hard way that clients could very easily shovel food off of their plate down to their dog and we wouldn't recognize that that. Okay so now we have to do check-ins with the food. We at first, we're going to try to figure out how to incorporate outpatient providers more. We found these miracle inventions, these scales that don't actually show numbers on them. They just report into like an electronic medical record system so that clients can get on a scale, we can send a scale out, the clients get on a scale, they're not seeing their weight. So we've found some workarounds for things that are risky or problematic when you're not in a brick and mortar facility. We've had to have some pretty structured expectations around how clients are showing up to treatment, that you're not horizontal in bed with a laptop sort of resting on your chest that you're sitting up and alert and have an appropriate environment around you. Helping clients to create the environment with which they're zooming in was really helpful too, because all of us were segueing into this virtual life. So all of us were having to learn how to set boundaries, time, boundaries for ourselves, space boundaries for ourselves so that we can participate meaningfully. A lot of our clients, of course, are students and so they were also being able to use those skills transferring those to their academic life too, which was cool to see. So that was sort of an added benefit of being able to help clients sort of acclimate to all of these changes that were going on. [DR. CRISTINA] So from my end as an outpatient therapist, I saw such a change in the number and severity of eating disorder patients and also just the lack of ability to get them into a higher level of care. I'm wondering for you, like being on in the higher level of care arena what was that like for you? What did you experience? [HEATHER] Yes, yes. It was really, it was awful. We had wait lists that we couldn't accommodate and having to triage some of that was really brutal and recognizing that we had to change the way that we were approaching clients because the things that we would ordinarily be asking them to reach out for extra support weren't available to them. So it was no longer go to a friend's house. It was no longer go for a walk with a loved one. It was no longer, there were no longer all of these things, or even distract yourself in work or academics or there wasn't the sort of, we had to learn how to draw on what was available. You remember what was available at the time was very little. I think especially with eating disorders, the uncertainty, the fears of what it feels like to sort of not be in control and to not have the things at one's fingertips that they had used to help regulate their own emotionality, aside from the eating disorder, was really, really challenging. So we had to, in some ways almost sort of recalibrate what our expectations were because we couldn't ask somebody to go to the grocery store as an experiential. So how do you recreate some of that stuff? Or if somebody's in our treatment programs, how do you incentivize folks who are ambivalent at best about being in treatment with a outing when there's no such thing as outings? So there was a lot of retooling and I think it had us as clinicians and as providers doing a little soul searching around how do we at least try our absolute hardest to make this treatment as effective as it would've been pre pandemic? I think we use the sort of gold standard eating disorder exam questionnaire, the EDQ as sort of a measurement of how our clients are doing both at admission and discharge, and feel really fortunate that we still saw the same level of recovery happening in our programs, whether they're brick and mortar, virtual through the pandemic we're still in it. That to me is the greatest indicator that we did things the best we possibly could, and they turned out to be enough which is a really, I think, heartening feeling for us as providers, that we were able to figure this out and pivot enough that people were still able to achieve recovery in our programs, even with all of the modifications you had to make. [DR. CRISTINA] So if you sit back and think about maybe why there was so many more people coming forward with eating disorders behaviors and symptoms, did you guys sit back as a clinic and go, why is it happening? Like, why so much now? [HEATHER] Yes. You think about some of the unique features of an eating disorder. So self-monitoring, huge one, anxiety, huge ones, social isolation, over fixation on food, over fixation on body, even dovetailing into increased social media use where there's all these social comparisons going on. So all of that that I think is so important to consider when we're thinking about eating disorders and that huge uptick that we've seen in prevalence. Then you also have all of the depression and anxiety that are precursors to eating disorders being that much more ramped up. So we know that eating disorders happen as an attempt to regulate one's self, one's own emotionality. If you're staying within that window of tolerance and you're cruising along just fine, you don't need an eating disorder. But if you're predisposed to anxiety, depression or you're not, and this has just thrown you into increased anxiety and depression and eating disorder along the substance use and self-harm, and all of those kinds of disorders, we know that there's going to be an uptick. That's a very predictable pathway for a lot of folks when you think about aggregate populations. And so it's of no surprise, but it's also just really heartbreaking because the access to care has not been able to keep up with the need. So we're seeing, especially, I mean, if I'm honest, the adolescent population is tremendously underserved and Alsana, we don't even treat adolescent. This is, I think a hopefully, a call to arms for adolescent providers that can increase care. But Alsana is one of the few programs that does treat all genders, that treats vegan clients. There are sort of populations of folks who really don't have the access to care that they need. That's been for all of us and I'm sure those of you guys working at lower levels of care are struggling to figure out where to place somebody when their needs are exceeding what you can offer at an outpatient basis. It's a really, really tremendously difficult place to be in, [DR. CRISTINA] I mean, yes, the more providers, the better. Specialists are hard to come by but alone too. I'm wondering for you for finding people to discharge your patients too, was that also a challenge? [HEATHER] Yes, especially one, psychiatry specialists trying like support groups and whatnot, I mean, it's just, it's harder to find these kinds of resources. I think it's also, I mean, I don't know if you're seeing this, but what I've seen too is that there's also sort of a different reluctance to step into higher levels of care too. So you have this need and there is an access issue, but then there's also an ambivalence piece because folks have missed out on so much life over the last couple of years. So to check back out of life in order to pursue a higher level of care after they've already given up so much after we've all given it up so much, that's a really tough sell too. So I think that there's, I don't want to not include that as part of the conversation too, that even though access is an issue, the motivation to pick up and uproot to go pursue higher levels of care is also a real barrier. [DR. CRISTINA] So with that, do you find that people are more open now since the pandemic to wanting to do virtual treatment than they've ever been before? Or do you think that that's something people are really hesitant to do? Where do you think people are at with that? [HEATHER] Yes I have an interesting sort of take on this, which is that I think that the generation that, of folks that we tend to treat in eating disorder treatment programs. So eating disorder treatment programs, for better or for worse, they tend to be a younger crowd. There's definitely outliers, thank goodness. We have some variety in age and gender journal of that but we tend to see a lot of young people, and these are young people who have grown up in front of screens. So we can sort of limit some of the impact of social media and electronics use and all of that but these are also generations that are used to receiving services or engaging in a way that feels authentic and meaningful in front of a screen. So we've seen that as a bit of a payoff. Now for our older clients, that's not necessarily something that they're going to, that's not what they've been raised with. We've seen some great successes in all age groups, but I do think that that's been an important piece. There's also the payer piece. I think insurance companies recognize that higher levels of care within the virtual space, there's a demand for that. Rather than wasting two hours coming and going on the freeway back and forth to a treatment program clients are wanting to be able to integrate it, integrate mental health services into their day-to-day life, which I love. I think that's so beautiful and if that means that somebody gets to go to treatment that wouldn't ordinarily be able to go to treatment because they don't have that commute time, I just think what a brilliant way to proliferate care for those that need it [DR. CRISTINA] Right now, just as you're talking, I'm wondering, too, if it's beneficial for families too, because I know when I talk to families about higher levels of care, they just go, gosh I don't, I can't imagine like one of us as the, if it's an adolescent or a child, one of us as parents, like staying at a place near the residential center or that's a big ask for families. That's a big stressor. I'm wondering if you found that offering the virtual treatment was something people were like, oh, that sounds so much better. [HEATHER] Yes, absolutely. I think for some folks it's so stressful, let's say the PHP level of care, to balance a PHP program with a job or school. If you're having to go back and forth, that's the opposite for our clients. That's just more stress and more sort of hustle and bustle and less self-care. So yes, there have been some folks that have really benefited from that, and it's not for everybody. We know that, and of course we still offer brick and mortar programs at all the levels of care and all of our facilities but we've definitely recognize that for folks who are interested in those services, that they can be really, really beneficial. We see great clinical outcomes from those clients. It's just been a real, I think a real eyeopener especially for eating disorders. I don't know that there, I think even in my own mind, if I'm honest, prior to Covid, I was uncertain about how that was going to go with eating disorders specifically. We were always sort of the unique snowflake of mental health of like, no, we have to eat with our clients and we have to see what they're eating and what their portions are. We have to be, to your point, seeing them below their shoulders to make sure that they're not having significant weight changes so that we can help to assess how they're doing. But we have found that there's just a shift in how we can operate and hold clients accountable and also support them and cultivate a feel of sort of honesty and a culture of accountability on client's parts and also on their support systems. We've learned to lean on support systems more than we had probably previously in the past. [DR. CRISTINA] I mean, I don't know about you, but if someone had asked you pre-pandemic, oh, do you think that virtual therapy or virtual, like higher level of care treatment is going to be a thing that is going to stick, what would you have said? [HEATHER] I had some, I've had some faith in knowing that this is the direction we're all going to be going in. So ultimately, but the speed at which we had to ramp this up is, I don't think anybody could have predicted this, but also the ingenious ways. I mean, if I want to give credit where credits due, our clinicians have invented this thing. They're the ones, the ones that are meeting with the clients day in, day out and trying new things and navigating these challenges and barriers in the moment. They're the ones that have perfected this thing and the creativity, what is it, necessity is the birthplaces of creativity. So I think that there's been a real sort of joy in watching our clinicians navigate this, they've thought of things that I never would've thought of in a million years. I've been doing this for a decade and a half at this point. So I've just been really impressed by all of that too, and the motivation to continue to evolve to meet that need as well. [DR. CRISTINA] I really love what you said, the outcomes were good, because you don't know when you start something different and new, like, what on earth is going to happen? It's a little scary. Like, doing something totally different that you've never done before, like, oh gosh, I hope this is just as effective or helpful or worth it, or what's going to happen here? [HEATHER] Yes, And that's, we have to be data driven because we have to be honest with ourselves right about what's actually happening because we can have a felt sense that people are getting better, but unless we're collecting good clinical data we can't really be accountable to our clients. So we've done just that and we've continued to see really, really tremendous outcomes. So that's been a real joy and relief. [DR. CRISTINA] So if anyone's listening and they're thinking, oh, I would never want to do like virtual treatments, or I'm really scared about it seems a little daunting or not something I'd be into, is there any like, real benefits that you see for someone who might be a little hesitant to try it? [HEATHER] Yes, I think that there are a few things. I think one, people tend to be more authentic when they're from the jump when they're at home engaging and so I think some of that, the newness of a new community of peers can be really daunting for some people. Some people find it exhilarating or exciting or a non-issue but for folks that are more reluctant to engage more vulnerably, I think there's something about being in your own space. I've got young kids and so I know what it means to have to schlop people around and try to balance everything. So I think for folks that have responsibilities that would ordinarily prevent them from accessing care on a regular basis or that might truntate their length of stay because they're needing to go handle conflicting priorities, I think that it's definitely worth a try. I know that our clinical team have really, again, done such a good job of meeting that need and learning how to operate within that space that the expertise is there from the provider. Yes, I think that there's something really bene, I remember one of our dieticians saying is having a dietary session with one of with one of his clients, and he could hear the food cooking in the pan while they were doing the session. I mean, just the sort of real-time support in somebody's home environment can be really beneficial. There's no gap with them. There's no translational process between a brick-and-mortar facility and what folks are doing at home. That to me, I think is just a, it's a really beautiful opportunity for some folks [DR. CRISTINA] I think that's so true, just being in their environment and there's just that comfort. That's something I found too, people are saying, oh, it's so nice to be able to be in my safe space, in my comfy clothes, to just be, and not like the stuffy office that maybe it was stuffy to them when they first started or something and not to have to schedule two hours just to get there and the session and to get back. It was really just the time of the session not extra. It's a lot less stress. [HEATHER] Yes, definitely. Definitely. If that gets folks to come in, then that's great. If that's what gets people to engage in treatment, then I love that. Then there are also programs Alsana is still offering brick and mortar IOP and PHP for folks that, I'm an extrovert by nature, and so I love being around other humans, and I've found that to be really energizing and comforting, and there's nothing better to me than community in that way. So I would probably be somebody who leaned to more towards a brick and mortar facility if I had ever needed to get services in some way but I also recognize the need for both. We've had very little to no community spread of Covid in our facilities. We've done a tremendous job of keeping everybody safe and engaged and our staff eats with clients still. We just do a plexiglass that everybody's safe. We've been able to work around the risks and still engage in really meaningful treatment and again continue to meet clients with where they're at in terms of their comfort level with being out and about or in a treatment program or at home. [DR. CRISTINA] So do you see, have you seen things shift and change as the pandemic has shifted and changed, like in terms of the severity or what people are coming in with in terms of their eating disorder symptoms? [HEATHER] Yes, that's a good question. I think that we're seeing less isolation. So I think a lot of the clients that we treat are actively engaged in a social life to the extent that their eating disorder is allowing them to be so that part of things I think is really nice. Where I think we're struggling still is looking at weighing, I sort of mentioned this earlier, but weighing at the need for taking a leave, weighing at the need for spending time away from school or job when so many folks have had to do, that they were forced to do that because of the pandemic. So that part of things, there's almost this sort of like rebound effect of everybody has been so contained and so out of control with how their lives are looking that, to ask somebody now to give up some of what they're working on or doing at home, or they've got going on in life in order to pursue their own health. It's a really hard sell, delaying school, which is sometimes required. That's a really hard sell for somebody who's spent the last two, three years in virtual classrooms [DR. CRISTINA] Just wondering your take on things, do you think that, like you said, you had a big long waiting list, do you think that that was by virtue of there was more awareness of mental health issues just in general? I mean, the pandemic really did, thankfully that was one good offshoot, I think, like we talked about mental health issues more, and I don't know if people were more aware and then therefore more comfortable talking about what they were going through and seeking help. Or do you think really like the pandemic itself, there was something about it that people, if they had eating disorders maybe before they got triggered and they came back, or they just, there was something about it that eating disorders became more prevalent during the pandemic? [HEATHER] Yes, I think yes, to all of that. So I definitely think that we're now in a time where folks are so hooked into social media for better, for worse. Again, there's a lot of mental health focused social media now so reducing stigma, folks talking about their own struggles and so I think part of it definitely is a growing awareness and acceptance that mental health is a health issue and that we can talk about these things, that there are resources out there. There's thousands of testimonials on YouTube about somebody's mental health struggles and sort of giving language to all of that. There's so many different avenues, celebrities talking about their own experiences and whatnot. So I think that's definitely part of it, just in terms of both the stigma and also the awareness, giving people language for it. But then also when, when we talk about the character profile of folks struggling with an eating disorder, again, somebody who's really struggling to manage their own anxiety or depression and are looking for a sense of relief, well, gosh the pandemic caused anxiety and depression for all of us. So when we think about people who are predisposed to an eating disorder or who have that unfortunate convergence of all these factors, of course, we're going to see more suffering, more struggling, of course, we're going to see people engaged in more self-monitoring and introspection and self-awareness or body awareness than maybe they would have and reclaiming a sense of control when the world got out of control. All of us, were wanting and craving for a greater sense of control. When the only thing you can control is what you're eating, what your body looks like, how you treat your own health, then of course that becomes really, really attractive and quite frankly, a really probably effective distraction tool when everything else seems to be crumbling around. Now we don't want that for anybody, but we know that eating disorders do serve a purpose. Otherwise, people wouldn't be unfortunately falling prey to them. So yes, I think all of those things happened and I also think that perhaps for some folks they've been putting off treatment and this was the time to do it now that they didn't have school, work commitments or there certainly could be a smaller population of folks who capitalized on the sort of slowing down of things in order to take care of their own health. [DR. CRISTINA] As you said, lots of different factors that led to all this. I personally think it's fantastic that there was, you said, more awareness about mental health issues. So the more we talk about it, I think the better. I appreciate you talking about how there's more availability of treatment just because there's been this open door to virtual treatment. There's more availability, there's more access. I think that is one thing that's been a benefit. [HEATHER] Sure, and yes to get payers to sign on too that they'll be covering these things is just a really solid step in the right direction, I think for where we really ultimately need to go, which is to elevate behavioral healthcare to the same level that medical healthcare is elevated and to increase access and reduce stigma and to increase evidence-based practices and quality care across the whole country. I mean, there's still a lot of work to be done. In some ways I think Covid has hyper sped up some of our growth in that area. There are of course monumental backslides right, in terms of the mental health of Americans, but in some respects, hopefully my hope is at least that some of that infrastructure is now in place that we can continue to build on. [DR. CRISTINA] Just tangential to that, so virtually if somebody's not in your state, how did, how does that work for you with virtual treatment? [HEATHER] So complicated. The early parts of the pandemic and actually for a good solid, probably a year and a half, two years states had relaxed their protocols so folks could, so as long as there are executive orders in place, folks could operate across state lines in order to increase access to mental health service, which was really great. So we operated in that way. In the meantime, I don't, I can't speak to other providers, but what Alsana was doing is steadily getting their clinicians licensed in multiple states, which is exactly what you have to do. It's a logistics nightmare in terms of paperwork and application fees and all getting everything else submitted, but ultimately that's what you have to do. [DR. CRISTINA] Yes, I was just curious because I know it's shifting and changing and that was something that was, I wish it would've stayed personally. [HEATHER] Yes, it was, yes, we were all sort of manically looking out for the executive order end dates and extensions and all of that, because we just knew that this meant people people getting access to get here or not. So it was just the sort of brush process of making sure that we could stay operational and meet the need. We were quite a bit, we definitely capitalized on our ability to do that and got a lot of people the support, the recovery support that they needed. [DR. CRISTINA] That's great to know, so anyone listening --- [HEATHER] Yes, if you need tips, we learned all the things the hard way, so happy to share any wisdom. [DR. CRISTINA] Well, so if anyone does want to know more about the treatment Aslana offers or find you how can they do that? [HEATHER] Our website is of course a great first stop but folks can always reach out to me directly, any of our leadership team directly. We are team players and want everybody to help increase access to care and help everybody succeed in their recovery trajectory and their process. So whatever we can do to help boost the whole industry and the field, we're really happy to do. Yes, I would definitely encourage for anybody that has other questions or wants to connect or reach out to me directly and yes, be happy to connect. [DR. CRISTINA] Awesome. Well, Heather, thank you so much. This has really been a good conversation. It's been long overdue and just really appreciate it. I hope anyone listening who's just wondering how to access care virtually maybe you're in a rural area or something, just know it's available [HEATHER] It's available. Yes, take advantage. [DR. CRISTINA] All right. Well thank you again so much. Really appreciate your time. [HEATHER] Thanks, Cristina. [DR. CRISTINA] This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.