Elizabeth Jarrard, MS, RD, LDN is a fellow blogger, with Guiltless and Don’t White Sugar Coat It, and a registered dietitian, practicing with Marci RD Nutrition Consulting in Harvard Square. Elizabeth specializes in eating disorders, as well as medical, sports, and plant-based nutrition. She is known for her ability to challenge eating disorder beliefs with a well placed ‘So?” I have asked Elizabeth to explore with us how eating disorders are maintained and treated from the perspective of a dietitian.
Thank you so much for joining us, Elizabeth. As recovery professionals, we frequently talk about changing a relationship with food. What does that mean from your end of a treatment team?
Active eating disorders distort your relationship with food. Food is in many ways throughout an eating disorder–as a means of control, as a way to cause pain, as a way to numb feelings, and many other ways. Food is transformed from something that is nourishing and life-giving into a tool of destruction. It becomes an abusive relationship that is hard to quit. As a nutrition therapist I work with my clients to remove the shame, fear, and guilt associated with food, and bring them into a healthier relationship with both food and their bodies.
In both your blog and in work with clients, you advocate for variety in what a person eats. How does variety contribute to ED recovery?
Variety is the spice of life! First, variety is important in eating disorder recovery just so we can ensure we are getting enough macro and micronutrients to support health–especially brain health during the recovery process. Second, variety helps to move clients out of the narrow constraints and ruts that eating disorders love–that false sense of control.
How does variety relate to balance? How do you know whether your day was balanced in relation to food?
Great question. Variety ensures that we are not feeding into the confines and constraints of an eating disorder. Balance is another goal of eating disorder nutrition therapy. I believe there are no “good” or “bad” foods, and it really comes down to moderation. Saying that we can never have a pastry again, sets us up for failure. Balance is having a pastry when we are hungry for one, and able to mindfully eat it and assess how it makes us feel. When you eat in a balanced way, you should have consistent energy levels throughout the day–avoiding huge slumps and feeling well nourished. At the beginning of eating disorder recovery meal plans can be an effective way to start to find balance. In working with a dietitian that specializing in eating disorders, you can find a meal plan that works with your life, and helps to find balance.
Clients often say they are afraid or even terrified to feel hunger. What are your thoughts on dealing with it?
Depending on where you fall in the eating disorder spectrum, hunger can be a very scary feeling. It may come as a surprise if it is something that you have tried to actively suppressed. Or it may be something you are used to numbing and soothing during a binge. Hunger can feel uncontrollable. It is important to pay attention and relearn your hunger cues. i often work with clients on learning to identify their hunger using a hunger scale (one like this http://medweb.mit.edu/pdf/hunger_scale.pdf). This requires tuning into your body and noticing how you uniquely experience hunger. Our goal is to avoid being at either end of the hunger scale spectrum. We can do this by nourishing our bodies, and becoming more in tune with what our bodies need.
We often come across clients who are athletes or need special diets for medical reasons. Unfortunately, we also see things like over-exercising or being overly focused on “allowed foods” that fall into the ED category. How do you help clients find that middle ground? To keep things, like exercise, that are important to overall health, but also back away from obsessive behaviors?
No one said the middle ground was ever easy. If a client is able to, I recommend switching exercise types while decreasing overall duration and intensity. For example, if they have been overexercise by running, we’ll start to decrease their mileage, while incorporating different types of exercise like yoga, or light cross-training, to begin to move away from obsession on one track. Exercise can be useful for both health and recovery, but not when done excessively. Yoga can be very therapeutic in the recovery from eating disorders.
For clients with medically required special diets, we work on incorporating more fear foods and expanding variety within their constraints. Even if a client has food allergies, there is usually still a lot of variety we can work in.
Thank you so much Elizabeth! It’s always so interesting and helpful to hear about recovery from your perspective. For more information, please contact Elizabeth at firstname.lastname@example.org or c: 307.349.0503. You can also check out her blogs at Guiltless and Don’t White Sugar Coat it.
Hi everyone! I’d like to introduce Tetyana, founder of the critically acclaimed blog Science of Eating Disorders. She has made it her aim to “facilitate knowledge synthesis, translation, and dissemination” of the peer-reviewed literature relating to eating disorders. Awesome goal, no? I asked Tetyana to be interviewed because she has become such an important resource for me in keeping up-to-date on all aspects of EDs, not just treatment. Trainings and classes are great, but there’s nothing like a good blog to keep you in touch.
Tetyana, thank you so much for agreeing to this interview! I’ll be honest. Narrowing down my questions was difficult, but I’d like to start with the origin of EDs. When trying to understand the origin of EDs, phrases like “perfect storm” are thrown around. Can you tell us what that really means?
I don’t actually hear that term very frequently, but it refers to the fact that eating disorders – like most other mental and physical disorders – are the result of a complex interaction between our genes and the environment. A phrase I like more is: “Genetics loads the gun, environment pulls the trigger.” (I do dislike that both refer to violent events or violence.) There is a range of genetic and environmental factors that can predispose an individual to develop an eating disorder; it is not a “perfect” storm as much as it is a range of conditions, on the genetic and environmental spectrums, that predispose someone to develop an eating disorder. I think it is important to emphasize that genes code for proteins, not complete behavioural traits, but in concert, our genetic makeup plays a big role in how we process information and respond to it — how we feel, think, and/or behave. Differences in various genes can affect these processes – sometimes in subtle and sometimes in not so subtle ways. The environment – and that includes the environment in utero and early childhood experiences – can interact with and modulate the way our genes are turned “on” or “off” and further shape how we feel, think, and/or behave. These complex interactions, which we do not fully understand, predispose some individuals to, for example, develop an eating disorder. But it is important to stress that when we talk about genetic predispositions, environmental stressors, or the effects these have on the brain, we are not talking about things that are permanent and unchangeable; they are not.
People with eating disorders suffer quite a few consequences, but continue to engage in the behaviors. Can you speak to the factors that maintain an eating disorder.
With respect to maintaining factors, I can only really speak about restricting and bingeing/purging behaviours mostly because that’s what I experienced and what I tend to read about. I think the behaviours (restricting, bingeing/purging) become negatively reinforcing, by which I mean that they remove a negative or unpleasant state. The removal of an unwanted state (anxiety, for example) ultimately leads the individual to become compelled to engage in those behaviours, especially when they find themselves in those states (and of course that state could be constant, too). That’s just a component of what maintains it – there are others, of course. After a while some things become habits and environmental associations (bingeing/purging whenever in a particular setting) also form. Moreover, restriction alters the way we think and process information, and all sorts of other things. But I think the power of the behaviours to remove a negative state – even if just momentarily – is one of the biggest factors that maintain the disorder. In some ways the behaviours mirror addiction, I feel, though I wouldn’t extend that analogy further than it can go.
If you could change two things about the way eating disorders are treated, what would they be and why?
I think the biggest problem in eating disorder treatment is not the way they are treated but the fact that many sufferers (a) do not get the treatment they need and/or (b) do not get treatment quickly enough. Appropriate, sufficient, and timely treatment needs to be available to more people. People should not have to wait two years to get a spot in a treatment program. People who are struggling should not be made to feel that they are “not sick enough” to warrant the treatment they need. We cannot control our genetic makeup, we cannot control our family history, and we often cannot really control our environment and the events that happen to us, but as a society, we really can make treatment more accessible and more widely available.
Any given paper on eating disorders points to a “significant gap” in the literature around the origin, maintenance and treatment of EDs. What would you say is the biggest gap and where is the most need, in terms of research?
I do not actually think there are as many gaps as often portrayed – not as many as people sometimes think there are, anyway. And I guess it comes down to a question of priorities: Do we know a lot about the causes of eating disorders on a genetic and neurobiological level? No. Do we need to know those things in order to effectively treat eating disorders? Well, not really. People have recovered and will continue to recover without this knowledge. We know enough to make sufficient strides in the most important thing, at least on a clinical level: making full remission a real possibility for a lot more people. I am very interested in eating disorder causes and maintain factors, but when it comes to improving treatment outcomes we already know enough to make an impact. We know that one of the main predictors of recovery (that is within our control) is illness duration. The shorter someone has been sick, the more likely they are to fully remit from the disorder. We know that much, and that’s enough, right now, to really make a big dent in pushing long-term recovery rates up.
And I want to be really clear here: I do NOT, in any way, want to suggest that we shouldn’t be funding basic research nor do I mean to imply that we should stop trying to find treatment tools that will help individuals who have been sick for a significant amount of time recover. I love basic research, and I love good research. It excites me a lot. I think it is incredibly important and it shouldn’t be an either/or thing: either money for basic (or clinical) research or money for treatment programs. But I don’t buy the idea that we need more research in order to see full remission rates go up.
In terms of gaps in basic research, it is hard for me to say where it is needed the most because that depends on the end goal. I can talk about what I think would be really interesting to explore, though. I am interested in genetics and neurobiology, but I don’t think the tools (at least neuroimaging tools) we have right now are sufficient to untangle things at the level that interests me, personally. Something that’s more interesting to me personally and, arguably more doable, are questions surrounding diagnostic crossover: Why do some individuals crossover and others don’t? Can we predict who will and who won’t experience crossover at an early time point, and can we use that knowledge to help in treatment? What happens during diagnostic crossover OR during rapid shifts in behaviours (restricting for a few weeks, then bingeing/purging for a few weeks, or even changes throughout the day)? What do these shifts mean for personality and temperament traits (rigidity versus impulsivity, for example)? Mainly: How do we connect the dots and explain the differences we see between AN patients and BN patients in personality and temperament and in the prevalence of various psychiatric comorbidities with the fact that so many AN patients eventually crossover to BN? What does that mean in terms of ED causes, maintain factors, and eventual outcome? These questions really interest me personally.
I also have a hypothesis that I’m waiting for someone to test, which is as follows: I suspect that the onset of bingeing behaviours in an AN patient who has been ill for, say, 3-5 years with AN, is predictive of a better outcome (eventually, like 10-20+ years down the road) than for someone who, 5 years after becoming ill, does not develop bingeing behaviours. I’m waiting for someone to test this. (Always important to stress that I’m talking about general trends in large sample groups, not any individual person per se.)
Finally, Tetyana, I’d like to ask a personal question, if you do not mind. You have shared that you are recovering yourself and you’ve personally experienced different levels of care. Would you explain the role your passion for science and your blog has played in your recovery?
I am passionate about science because I am a firm believer that the scientific method is the best tool we have to uncover truths about the world. I try to hold onto my Sagan-esque passion for science. I think having a passion is always helpful in recovery; it can help keep someone keep being in recovery.
With respect to the blog, it is hard to say how it impacted on my recovery – it probably played a neutral to slightly positive role. The experience in general has been hugely positive, and being involved with something that is so fulfilling and so rewarding is, of course, good for anyone’s self-esteem and mental health! But in that sense, it played the same role as doing other things I find really fulfilling.
It is part of the package of how I’d like my life – both day-to-day and in the long-term – to proceed. I’ve made a lot of conscious choices about how I want my life to be structured (and I’m particularly lucky to have the privilege and ability to do so), and doing science blogging is part of that picture, but not a major part. I started the blog when I was particularly frustrated with graduate school. I just wanted to have something I can work on after a week of failed experiments that amounted to me feeling very unproductive and generally low. I thought of it as my little project and if it went well, I’d continue, if not, then, oh well. I got way more positive feedback than I ever expected, and so in that sense it is been amazing. I especially love that the comments on the blog posts are intelligent and interesting, and the diversity of readers — from those personally affected with eating disorders, to carers, clinicians, and researchers — it is amazing. I love criticizing papers (I always loved journal club), I enjoy coding/playing around with PHP and HTML, making figures in Illustrator, and obviously I like editing, so it is a nice mix of all of these things I like.
In terms of recovery, I don’t have any secrets. I don’t consider myself recovered; I am not. I just don’t find my eating disorder really gets in the way of things. It doesn’t get in the way of my social life, or anything. I am not overwhelmed with thoughts of food. I love my body. I maintain my weight, and eat what I want. But I’m not free every behaviour, and I do need to make sure I eat enough otherwise I easily slip into eating less, just by accident/habit. Being mindful of my mental state helped me a lot, doing things I find really rewarding also helped me a lot, and being in an amazing relationship also helped — a lot of things in tandem, really. No magic bullets.
I’d like to thank you Tetyana for sharing your thoughts with us today! Your honestly and blunt style is much appreciated. Also, You do a remarkable job and the ED community is very lucky to have you to keep us informed!For more information, please visit Tetyana’s blog Science of Eating Disorders, where she and other contributing bloggers explore the research around eating disorders.
Hi everyone! I recently had the great privilege of interviewing Dr. David Brendel. I have known David for almost two years now and I just adore his style and approach to clinical work. He is, in the truest sense, a humanist scientist. He brings a flexibility and creativity to the science of clinical work.
On top of that, David has a scary impressive resume. David has a private psychiatry practice in Belmont and a is a Certified Executive Coach with a practice in Boston called Leading Minds Personal and Executive Coaching. He is the Medical Director of Psychiatry at Walden Behavioral Care, an treatment facility that offers a continuum of care for eating disorder and psychiatric patients. David earned his M.D. from Harvard Medical and his Ph.D. in philosophy from the University of Chicago. He has a dozen or so peer reviewed articles, multiple book chapters, and is the author of MIT press book Healing Psychiatry. And because he does not have enough to do, he also host a radio “Leading Minds with Dr. David Brendel” and consults for several major TV networks.
You can see David is a bit of a psychology renaissance man, making him the perfect person with whom to explore the complex nature of eating disorders.
Below is the audio for the interview. There are also a few moments where there is a leaf blower in the background. I did my best to take it out but I’m sorry for any problems it cause!
3. Going into a higher level of care can be a terrifying and distressing process but so can leaving a treatment center. Treatment centers provider 24 hrs of support and validation. How do you help clients “take that home”, for lack of a better phrase?
They can’t take that home. They have to build support and validation within themselves. And they can’t do that until they are in solid recovery. It’s a shock to leave a safe place and enter the unsafe world we all live in.
A quality eating disorder treatment center gives clients tools to use when they are in trouble. It shows them the kind of support and validation they can receive from community. It shows them they are lovable and that they are not their symptoms. It shows them that they gain respect from others and perhaps themselves for working toward recovery no matter how they fall and act out their disorder.
It shows them that they are not alone, that some people have more health than they do, and some people are more sick and troubled. Clients discover they are not unique and isolated because of their disorder.
And, if they are lucky, they will see someone go through a crisis with supportive and understanding professionals who work with that person as she descends and emerges with new learning and a stronger sense of self. All this adds to a realistic sense of hope and a determination to continue recovery work.
If she thinks she can go to a treatment center and come out healed and ready to be on her own she is in a fragile and unrealistic position. If she can use what she’s experienced to be able to tolerate her feelings more without acting out as much she can appreciate the ongoing work that is necessary for her full recovery.
Then, if she’s working with me, we can draw on her residential treatment experiences to add understanding and strength to her every day living as she learns to stand on her own.
It’s very difficult to stand on your own when you have an eating disorder. That’s why clients are so afraid of recovery work. They don’t realize that recovery means you can stand on your own because you don’t have an eating disorder anymore. It’s difficult to imagine being without an eating disorder when you’ve had one all your life. But, step by step, day by day, appointment by appointment and achievement by achievement, recovery comes.
4. Many in recovery are terrified of feeling hungry and go to great lengths not to feel it, whether that means restricting or binging. As the author, “Healing your Hungry Heart,” what are your thoughts on facing hunger?
Ah, hunger. It’s such a natural word to go with food and eating, isn’t it? People with eating disorders usually have no idea what hunger is. They eat for emotional reasons. They are hit with massive cravings. They may be ravenous from starvation yet not recognize a normal feeling of hunger. They will use the word, hunger or hungry, but it’s not connected with genuine hunger. It’s more about filling themselves up completely so there’s no room to feel anything.
Or it’s about keeping themselves empty and feeling at home with that feeling, even if their bodies are shriveling away.
I remember a client who called with me great happiness and excitement. She was at a sushi restaurant with friends, eating one mouthful of food at a time. She said, “I lifted the next morsel to my mouth and didn’t eat it. I was hungry when I started the meal and then I wasn’t hungry anymore! I knew that the last bite satisfied me. This next bite could be the beginning of a binge, and I didn’t need it.”
She was elated because she found out what hunger was.
Your question addresses the real situation of people with eating disorders who are terrified of feeling. It’s difficult or impossible for them to distinguish physical feelings from emotional feelings. Almost any feeling needs to be avoided.
Your readers may object to my saying this by responding, “But I do feel. I feel angry or sad or scared at times. I feel happy when I do something right and get praise. I love to dance and workout.”
My response to that objection is, yes, of course you have those feelings. They are a narrow range of what a human is capable of feeling. Most of the time what you feel is a great intensity, a rush that can be overwhelmingly good or bad. Overwhelm is the operative word. A surge of intense feelings overwhelms the broader range of human emotion. Those emotions give you information about your life, your experiences, and your relationships. They call attention to what is good in your life and what needs correcting. As you develop your own stability, sturdiness, sense of self and inner competence you become able to face what your authentic feelings are showing you about your life.
My book has exercises after each chapter. They look similar, but they are tweaked to help you go more deeply into your psychology in gentle stages. If you do the exercises in Chapter 2 every day for a month you will learn more about yourself, and you will develop new strengths. Those strengths you will use when you do the exercises at the end of Chapter Three every day for a month. And so each chapter exercise equips you to move to the next with more recovery than you had before.
When you finish the book you can start again. The Appendix has more exercises for each chapter. Healing Your Hungry Heart is designed to be a long time companion on your journey to recovery. You can use it as a fresh experience for years. I hope you will write to me and let me know when you discover your real feelings of hunger so I can celebrate with you.
Thank you so much, Joanna. I deeply appreciate that you took the time to answer my questions and I am excited to see how the responses from our readers and clients!
Thank you, Casey. It’s a pleasure to respond to your thoughtful questions. Your readers are lucky to have found such a caring and conscientious clinician who works on their behalf.
Please share your thoughts on Joanna’s answers.1. What can you share about your experience in coming out of residential treatment that might help others?2. What are you learning about hunger and learning the difference between craving and feeling hungry?3. What is working for you?4. What kind of support do you need now?
Joanna’s website is: http://www.eatingdisorderrecovery.com.
Healing Your Hungry Heart, published by Conari Press, is
available at Amazon, Barnes and Noble, Gurze.com,
Books a Million and bookstores. Joanna’s private practice is in
Los Angeles. She also does long distance Skype consultations.
To reach her write Joanna@poppink.com
Hi everyone. I’d like to introduce Joanna Poppink, MFT. She is a licensed psychotherapist in California, the author of “Healing your Hungry Heart: Recovering from your Eating Disorder” and a fellow recovery blogger. I found her blog a while back and have loved the how she covers many different aspects of eating disorders and recovery, from cultural influences to inner child work. In my blog and with my clients, I routinely explore the origin, maintenance, and recovery from eating disorders. Joanna has graciously agreed to lend her expertise to me and my readers.Joanna, thank you so much for sharing allowing me to interview you! Eating disorders are so very complex, as is recovery. I have tried to narrow my questions to topics that come up often.1. The first I’d like to bring up is around family culture. So often we see family cultures that support and nurture eating disorder beliefs and behaviors. What are your thoughts on how to survive or get yourself out of such an environment?
I’m glad you asked for thoughts and not answers, Casey! This is such a challenging issue.
Working toward becoming a mature, responsible, competent and self confident person is the developmental path by which we find health, the ability to deal with complex issues and the ability to tolerate ambiguity and stress while proceeding in our individual lives. When we are on such a path we are free to say “No,” to what is not good for us. That means we can stand up to forces, including people, including family, who press us to accept something that goes against our authentic needs and values.
A person with an eating disorder can’t do this very well because when her eating disorder started a section of her development stopped. The eating disorder takes care of discomfort, challenges, uncomfortable feelings and certainly helps block even the awareness that standing up for herself is necessary. When she can’t tolerate her feelings she might continually defer or be emotionally numb or seethe within yet be unable to be understood by others. She may be unable to contain her frustrations and burst out with weeping or rage, neither which communicates clearly to the people around her.
If our eating disorder person, let’s call her Cynthia, knows her family supports eating disorder beliefs and behaviors, then she has some self awareness about her disorder and her recovery needs. In early recovery she may tend to believe that once she is aware of something it’s easy and reasonable to think others should be aware too.
“Why can’t they understand”?
“Why do they push food at me?”
“Why do they talk about my weight?”
“Why do they watch what I eat?”
“Why do they keep talking about what I do and don’t eat and how much I eat?”
What Cynthia needs to appreciate is that she is working hard on her recovery. She is working to change not only her way of eating but her way of life, her vision and perspective on what is possible for her in life. She is working to gain a new appreciation of who she is as she develops her dormant potential into her independent and authentic personhood.
Her family, most likely, is not doing this. They are living, behaving, believing as they always have. Family culture does not change because someone goes into treatment.
But this does not mean Cynthia has to leave her family. If she loves them, and they love her they can stay in relationship. The wonderful thing about a loving family is that the culture may be powerful but the love creates some flexibility.
Does Cynthia live at home with her family or is she an adult who visits? That makes a difference in terms of how she will deal with the stress of making a recovery place for herself within this culture. But it doesn’t affect the options she needs to explore.
To communicate with someone you have to speak their language. Cynthia’s family may not understand eating disorder language. By that I mean they may not understand psychological issues Cynthia is exploring. They may not understand why a cherished food that they have prepared for generations for holidays or breakfast or birthdays or dinner is now unacceptable.
So part of Cynthia’s recovery work is to discover what language her family will accept if not understand. Her goal is not necessarily to be understood. Her goal is not to have her family be as informed as her therapist or members of her recovery community. Such goals are wishes that lead to sadness and frustration for Cynthia. For her family such goals are bewildering.
As Cynthia becomes more capable of tolerating her feelings she can find her way. A common fallback position is: “I’m allergic to …..whatever foods are being pressed on her. Another is, “My doctor wants me to eat this much and in this way.” Another is, “I’m doing a writing experiment for work (or school or community project) about thoughts and feelings. When I feel or think something that’s relevant I’m supposed to stop what I’m doing and write it down.” If this is something the family can accept then Cynthia can leave the room at any time and go to her journal.
Key to these possibilities is Cynthia’s taking responsibility for finding her way through the family culture to her recovery needs. She works to find her way to make her environment support her recovery. She creates an oasis for herself using language her family can accept.
2. Motivation to recover comes from many different place, but often people feel like they do not need to address eating disorder behavior unless they are at the brink of some sort of crisis, like passing out at work. How do you go about finding motivation when the eating disorder is telling you everything is fine and “You’re not that bad yet.”
This is a fabulous question. What is it that puts a person on their true recovery path? Recovery takes time, energy, money, commitment. It means letting go of a way of life that has protected you from unwanted feelings and knowledge. It involves joy and, especially in the beginning, a lot of pain and tears. Why would someone want to go through all that if, as you say, “It’s not that bad” or “not that bad yet.”
I believe the change from going deeper into the eating disorder to climbing out of the disorder and into life requires several components.
The person realizes that her eating disorder is endless pain going to darker places.
The person realizes that the pain in recovery can lead her out and into freedom. Her choice becomes endless pain or pain with the real possibility of freedom.
She has a sense of hope that recovery is possible. This might come from within her or from being inspired by recovery she sees, hears about or knows from people in her life or from books or YouTube testimonials or 12 step meetings.
This point I’m less certain of. It’s about the availability of real help. Some people need to discover a source of real help before they surrender to recovery. Yet others surrender first and then find their help.
I’m a psychotherapist specializing in eating disorder treatment for thirty years. Some of my patients have been committed to their recovery and searching for years, trying different treatment methods until they get to my office. They found me after they became motivated to their recovery.
Others come to me enmeshed in their eating disorder. They come to check me out. Only when I win their trust do they begin to let go of their rigidity and find their way to their recovery path. They come because they are looking for help. They want and hope for a way to heal. But they are not motivated and committed until they trust our relationship and trust that I will go the distance with them.
Clearly, Joanna, you are very thoughtful and thorough in your answers! Much appreciated, I assure you. Given the depth of your thoughts, let’s continue this interview in the next post. Everyone, please stay tuned for the rest of the interview, to be posted on Thursday , November 7th, 2013.Until then, please feel free to share your thoughts on Joanna’s words.1. What do you find helpful in dealing with family culture that doesn’t support eating disorder recovery? 2. What motivates you to stay committed to your recovery?3. What parts of your family culture support recovery?4. What have you found in recovery that keeps you moving towards change?Joanna’s website is: http://www.eatingdisorderrecovery.comHealing Your Hungry Heart, published by Conari Press, is availableat Amazon, Barnes and Noble, Gurze.com, Books a Million and bookstores. Joanna’s private practice is in Los Angeles. She also does long distanceSkype consultations. To reach her write Joanna@poppink.com
Mended Wing Counseling is a group of therapists who focus on a variety of issues. Reach out to us at any time!