Monday 8th June
Dietetics Digest
Eating Disorders, Diet Culture & Trauma feat. Jessica Crawley
In this episode, we have Jessica Crawley. Jessica is a Highly Specialist Eating disorders dietitian. In this episode:
Resources Mentioned:
If you enjoyed the podcast, please can you support us by:
This podcast is supported by an unrestricted eduction grant from Nutricia.
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Monday 8th June
Dietetics Digest
Eating Disorders, Diet Culture & Trauma feat. Jessica Crawley
In this episode, we have Jessica Crawley. Jessica is a Highly Specialist Eating disorders dietitian. In this episode:
Resources Mentioned:
If you enjoyed the podcast, please can you support us by:
This podcast is supported by an unrestricted eduction grant from Nutricia.
Thank you for your support!
So what I mean by diet culture is this idea that it's admirable to potentially live in a smaller body or is admirable to be engaging in health behaviours. When I say health I'm using, you know, inverted commas, health behaviours, which means where we attach the way that we and the way that we move and the way that we engage with life to morality, and to moral value. So diet culture, I guess, is pursuing this idea that thinness is healthy. And that changing our eating behaviours are some way attached to our moral value that we're not as valid or that we have some willpower issue or there's something fundamentally wrong with us if we don't eat in a certain way or exercise in a certain way or live in a certain body. And diet culture really perpetuates this idea of the thin ideal and this idea that we have to be and look and eat and exercise in a certain way to be valid members of society. But of course, we know that's not true, because we're all different.
Aaron Boysen :Welcome to the dietetics digest podcast, a podcast that helps you understand more about the different areas of dietary takes on nutrition and what others are doing within them. We do this by talking to inspiring and influential individuals that are advancing practice in some way, shape and form. Our mission is to create a resource that helps dietitians to build, grow and share ideas with each other to help advance their practice and the practice of others. I am your host, Aaron Boysen. On this podcast, we have the guest Jessica Crawley. Jessica Crawley is a specialist eating disorder dietitian working in West Yorkshire. She is passionate about pointing people towards their mental health. Even in the midst of experiencing a mental illness. Jess approaches things with a focus on dietetics to help people connect with their bodies using an integrated body mind approach in order to help people understand where their experience is coming from, in an attempt to reduce the fear around it. Jess has been involved in the development of a group therapy programme for anorexia nervosa and embedding dietetics. Within this, she regularly facilitates training for health care professionals co facilitates and open support group for those who are struggling with disordered eating, and is in the process of developing a consensus guideline for dietitians, working with inpatient settings. So please welcome Jessica Crawley. First of all, I just wanted to start off with basically who you are, and how to sort of brief search on social media and you're not really on there at all now, and I wasn't able to do any snooping that I usually do. And so then find a little bit about Yeah, so maybe we could start off with a sort of classic question that I feel like everyone really asked. So why did you first want to become a dietician?
Jessica Crawley :Yeah. So I kind of stumbled into dietetics. And this can be a recurring theme. I like many 18 year olds, I had no idea what I wanted to do, but I knew that I was interested in science. So I went off to study and pharmacology and physiology at the University of Manchester always had this absolute fascination with how the body works, you know, in a real curiosity as a kid as Why does it know what it's doing without me having to know anything about it? So I was really Fascinating that which led me to studying physiology and pharmacology. I learned a lot about the pharmacology industry in that and really started to question some of the ways that modern medicine actually treats illness, not that I'm saying that it's wrong, or there's anything wrong with it in any way, shape or form. But, you know, really what I what I became understanding of was that it was very much symptom focused, illness medical model and go to an expert to treat you. And, and, and I was really curious about that and using using drugs in a way to to treat physical ailments. And I really found it interesting, you know, I did a degree in it. But then, as part of that, I got really interested in some of the nutrition models that models that were modules that we were studying, which you know, for me made made a lot of sense that we nutrition may be able to use to treat illness after certainly manage symptoms of illnesses. And so I went off to have a look at what was out there and found a postgraduate degree dietetics and was Yeah, loved it. And two years linking everything I knew about physiology with thinking about how we can look after our health from a nutritional perspective.
Aaron Boysen :It's really interesting that you came sort of down that angle that way. But more, I don't know, is there anyone else that you know, that have sort of gone down that angle before? Oh,
Jessica Crawley :no, I think I knew that I wasn't destined to work in a lab. I love talking to people. I love him experience in really immersing myself in the experience of others. And so I really started to look at how can I use my understanding of how the body works and my interest in nutrition and health to to link that with the experience of people. So I started looking at allied health professionals generally, and Dietetics just absolutely jumped out at me.
Aaron Boysen :And what sparked your interest in eating disorders in particular?
Jessica Crawley :Yeah, so I've always had an interest in mental health. I did my a placement in the mental health service. And because I knew that that was somewhere that I was always going to think about working in my mom's a mental health nurse managers and mental health nurse and growing uplift in house with my sister who had an eating disorder and So I guess I had experience from a lived experience perspective by by what my sister went through. And also from just living in a house where open communication is just the thing. And having been in a family of mental health nurses. And I was really, really interested in the model that mental health services use, which is, you know, putting the person's experience at the centre of everything and using a really patient centred approach. And throughout my placement, I really saw how mental health services were doing that and perhaps moving a little bit away from the medical model of illness.
Aaron Boysen :So you said a little bit about you're in a house of open communication, open communication, how would you define open communication
Jessica Crawley :just I think that anything goes and everything is okay. And so I lived in a house where you didn't have to be alone in your struggles. And if anything was was off with you if you were unsure about anything, it just even presented in a way where you weren't your usual self. It was it was talked about in my house, and my mom. My mom is one The most non judgmental open people that I've ever met. And she, and you know, actually, I lived in a house where my friends would come to my mom for lots of support and advice. So I think it was just that, you know, you can't say anything that would shock my mom. And, and the lack of judgement in that just meant that there was a really free flowing opportunity to share how you feeling and just a real understanding that our feelings are okay.
Aaron Boysen :And that sort of informed your role is sort of getting into mental health part of dietetics. And it's so interesting how they're sort of sort of your educational background influenced your sort of non educational but more cultural, familial background. And I wanted to talk a little bit today just so people can have an idea about the role of a dietician within say, an eating disorder service and what they actually do on a on a day to day basis. So what is what is your role as a dietitian in an eating disorder service? What do you do on a day to day basis?
Jessica Crawley :Absolutely. So it's a great question, because I think that you know, in terms of our experience of working in eating disorder services, it can be quite limited within our training. I know that we've started to recently embed a lot more education within the curriculum, certainly at Leeds, Beckett, actually, in terms of experience of working with people with eating disorders that can be quite limited, because there are so few placements that are for that. And so I think it's, you know, I think it can be useful for people to think about what is it that a dietitian does, and I think it's worth considering what the guidelines say. So the nice guidance talks about you know, nutritional interventions and shouldn't be doing on their own and in an eating disorder service, that nutritional rehabilitation and nutritional therapy is a really important part of anyone's treatment who is living with an eating disorder. And but it's not to be done in isolation. So it's to be done alongside any psychological therapy and psychological support. And that's really obvious and really understandable when you work in the area when you really understand what an eating disorder is, you know, it's a way of coping with something. And if we go in as dieticians, as with solutions and ways in order to move away from some of those coping strategies that can leave people feeling quite vulnerable. So it's really important that you have somebody alongside you to help us help someone to get through those feelings. And so I guess what our role is to help people to understand how their experience with food is manifesting physically, how much of their experience have a connecting with the way that they eat, as opposed to connecting it with who they are. And so I really see the role as the dietitian in helping people to understand that the way that you eat and your relationship with food will have an impact on how you feel moment to moment. And, and helping people to see that and connect with that can help them to see that actually reducing your food intake, restricting your food intake and using behaviours that really look like they're helping in the short term. Actually, when we zoom out when we look at the bigger picture, and when we look at the understanding of how the body works and how it would respond to such symptoms, how that might not be true. Because when you Help to even invite in a little bit of curiosity for someone that's living with an eating disorder, that not everything that they believe is true. You've got leverage to help people to think about doing something different.
Aaron Boysen :Okay, so you talked a little bit about what you're trying to do and how you do it. Yeah. How do you actually do it? Right? Yeah. sounds quite a great ambition. And yeah, where the outcome, how does it actually work on a daily basis? Like, what's the sort of nuts and bolts of it?
Jessica Crawley :So, the first step is assessment. So we have a really lengthy assessment process where we, you know, it's a typical dietetic assessment, if you like really understanding someone's experience with food over their lifetime, how that's changed how their thoughts about food have changed, and how that's impacted on their physical status. So we'll we'll do an assessment, looking at physical status, looking at blood results, looking at weight history, and looking at symptoms that they're currently, you know, behaviours that they're currently engaging in that might feel like they're helping them to curl up. And, and then what we'll do is we'll assess the impact of the If there's behaviours, and so we have a really, really thorough assessment process, you know, that can take up to two to one and a half hour sessions to just even begin to, to develop an understanding of what someone's experience looks like. And then we'll provide psychoeducation. So psychoeducation is a huge part of the role of a dietitian within an eating disorder service. So step one, understanding whether experience is coming from a really thorough dietetic assessment. Step two, trying to educate and help people to see actually what that what those behaviours are doing and how that might differ from their perception. And, and then we also in the service that I work in, we integrate ourselves into into therapy groups and supporting psychological therapists, our drama therapists or anyone our nurses who are delivering therapy to really understand the impact of malnutrition or poor nutrition on physical health and, and our mood also,
Aaron Boysen :so what do you think about sort of psycho education role and that kind of thing? Is it done on your own or is Do with other people in the room? Or is it is every sort of member of the MDT has the separate appointments? Or how does it How does it
Jessica Crawley :serve both? It depends on what setting you're working in. And typically speaking, we would do the assessment on our own. And we have regular, I think, you know, a multidisciplinary approach is absolutely fundamental to any eating disorders, treatment. And actually having lots of different perspectives in the room from different professionals is super important. Because, you know, there's this whole idea of something called transference where you can pick up on the emotions and the feelings of the person that you're working with. And, and as a team decide, as professionals, we are susceptible to that we are susceptible to becoming quite rigid and disordered in our thinking. And so having a really, really varied multidisciplinary team, looking at lots of different perspectives enables you to build a treatment programme that hopefully isn't mirroring the wholeness too much. And so we work on our own from an assessment perspective, but we're always feeding that back to the multidisciplinary team. And sometimes we work in collaboration with other professionals. So that's it with regard To the deliberate delivery of a therapy group, for instance, we go in and we support a therapist alongside them, integrating the dietetics into the therapy group, and therefore helping to connect both the psychological and the physiological recovery that was required in the treatment of an eating disorder.
Aaron Boysen :So that therapy group you talk about in your interaction, how does that how does that work? How does like, it wouldn't be the immediate, where I would sort of obviously, my knowledge is very rudimentary, but it wouldn't be the immediate place where I would go sort of thing. Let's get everyone together in a group. And let's get them all just discussing their own experiences. Yeah. What what triggered that? what triggered that train of thought? And how is it How does it work?
Jessica Crawley :Yeah. So it came from a couple of couple of areas. Number one, was just in terms of of, you know, the sheer number of people that were supporting and how can we really reduce waiting times and get people into the service quickly, and one of the best modalities for doing that is through a group therapy. The other thing to say is that you know, and I in our inpatient service, the vast majority of the treatment is in a group therapy. Yeah, in a group therapy approach, and and what what the feedback from that is typically that people find a peer to peer support and understanding that other people are going through the same thing as them really, really helpful. It's worth saying that having an eating disorder is typically a very, very isolating process. And so just being in a room with people who are going through the same thing that you are, and seeing that you're not learning, this can be a really, really powerful motivator for people in treatment. And so I think we thought that we had to think about a way that we could, that people could access treatment rapidly, and that we could serve as many people as possible. And we also had to think about what the peer element did in terms of supporting people. And it was initially just a therapy group, which was looking at, you know, psychological methods. But I guess another role of the dietitian is offering that other perspective in MDT meetings and, and thinking about the physical rehabilitation that's required. And actually what we started to question was, and could that be, be Spoken more readily and more often about by integrating that into the therapy sessions, and typically speaking people have found that really, really helpful.
Aaron Boysen :What kind of things would you speak about?
Jessica Crawley :Yeah, so we split it up into three modules. And we use an evidence based treatment called mantra, which is the market is approach and to the treatment of anorexia nervosa. So this was a manualized approach that was developed by the Maudsley Hospital in London. So, and it's, I guess it's quite, it's a worksheet based book approach, if that makes sense that where an individual therapists would go, it would work one to one with someone living with an eating disorder. So what we really wanted to do was lift that off the page, and with the, you know, one of our drama therapists Mary Franklin Smith with this part of the Maudsley hospital, and she developed this group programme that was split into modules that came from mantra. So those modules being identity, social and emotional mind, and thinking styles. So those are the three modules that you would explore within the group. And then what we've done is we've integrated a new set of nutrition links session to the end to each of those. So I guess the tagline being, you know, the way that your you nourish your body is going to impact on the way that you think a more flexible eating approach will support more flexible thinking. From a nutrition and identity perspective. We talk a little bit about what would maintaining an anorexic identity and how does that impact and manifest physically? And actually, how can we learn from the experience that we know in physiology, which is that our bodies are in constant state of flux and change and always trying to come back to balance? How can we also compare that to the experience of that of our mind and our mood? So we talked a lot about that we talk a lot about how what how our perceptions of body image might look fixed, for instance, but how that changes moment to moment just by the very nature of our physical experience changing moment to moment. So we really try and link the physiological experience with the psychological experience. If that makes sense. It doesn't,
Aaron Boysen :it doesn't mean that I'm sorry, it doesn't make sense if you could sort of static If I start again with the guy who's probably more me than
Jessica Crawley :Yeah, I'm so used to it makes total sense in my mind. Okay, so we deliver a group therapy programme called mantra. mantra is a manualized treatment approach that was developed by the Maudsley hospital. And it comes in booklet form. And it was typically designed for a one to one approach birth an individual therapists to talk somebody through their experience of living with an eating disorder. So to really understand how the eating disorder came about, and what keeps it going. And this is split into three modules. So it's understanding how the eating disorder impacts on our sense of identity. How having an eating disorder impacts on our ability to socialise and our emotional mind and our emotional resilience, and how having an eating disorder impacts on our thinking, and that's the therapy treatment approach. So what we've done is we've lifted that off the page and we've developed a group where people come in and explore those three modules in a peer to peer support way. So exploring who I am without the anorexia that's the identity module exploring how much The way that I think has enabled are maybe being really zoomed in on IV anorexia, you know. So I'll give some examples of the way that people think some people might be really detail focused, rigid, and in thinking patterns, other people might be able to hold a much more global perspective and be quite big picture thinkers. And so what we really explore is the individual thinking styles and then how having anorexia can lend itself to some of those thinking styles being more or less in you. So how flexible we are in our thinking, potentially, and how that limit that can become limited. And by having an eating disorder, that we explore identity we explore the way that people think and then we explore the impact that having an eating disorder might have on your, your social and your emotional mind. So your ability to socialise and or your ability to understand your own emotions or the emotions of others around you. So that's the core of the therapy group
Aaron Boysen :is making a bit more sense of how the disorder impacts on the physical sort of world around you and
Jessica Crawley :yeah, on your interactions, you know, we know People living with living with eating disorders talk about it being a very, very isolating and a very, very isolating illness. And so starting to understand how your eating disorder will impact on those, you know, on each of those areas of your life can be a really, really helpful way of thinking about how else she could experience life without having an eating disorder. So if you because if you think your eating disorder is who you are, it can be really, really difficult to imagine life without it. So we spend, we dedicate time during treatment to really exploring that
Aaron Boysen :make sense? Yeah.
Jessica Crawley :So I guess what we've done as dietitians is so we've integrated our understanding of physiology, and our understanding of how different steps of nutrition will impact on our ability on each of those areas. So for instance, how would a starving brand think much more like you know, in a starving brain, it's very, very difficult to think in a flexible way. In a starving brain. It's very, very difficult to to develop flexible and new ways of thinking because your brain is not going to be laying down New brain pathways in order for you to to adapt and respond to your environment, because it's going to be in a position of energy conservation and trying to just keep you alive. And so I guess what we go in and we educate people and we support people to see is how, you know, if your experience might look really fixed right now, you're thinking might look really stuck right now. But can you see how actually your nutritional status and the way that you're eating is perpetuating that? And can you see how actually having a malnourished brain would support you in thinking in a different way and support you in thinking in a more flexible way? And so we go in and we help people to understand the symptoms of starvation on the brain, and how reversing some of the symptoms can really help you to have a different experience,
Aaron Boysen :sort of struggles, what would you have in sort of teaching that concept to individuals and people? What are the some of the barriers that people may face in sort of adopting just
Jessica Crawley :and I guess it's really hard to imagine how it can be different and When you're quite stuck in your way of thinking, so I guess, a huge part of the work that we do is the ability to build a relationship where the person that you're working with trusts you, and where they feel safe with you what we know about eating disorders, that, you know, if you speak to someone's eating disorder, it will respond if you focus on the symptoms, and you focus on where somebody is that that is the part of them that will that will respond. So, you know, something that's really helped me in my practice is to speak to speak to the person's health speak to the person beyond the diagnosis of the eating disorder, and really get to know that and because, you know, even in the midst of living with an eating disorder, people have insight into what can be different for them. But it can just feel so overwhelming and so frightening to do something different, that it doesn't always look like a choice. And so I think that you know, what we really do is want to build a relationship with someone where they have that space and time to think that there are other perspectives available and then really guiding them through it.
Aaron Boysen :One of the ways you can speak to somebody is not their eating disorder to somebody through that.
Jessica Crawley :I think it's about just knowing that it's there. And I think that, you know, as dietitians, working in eating disorders, and I suppose we've got lots of experience of really understanding that where someone's asked, in this moment with their eating disorder is not who they are. So you know, your experience of Melton mental illness is not who you are, it just describes where you're at right now. But behind that, behind your experience of mental illness, there is some you know, there is someone who can experience mental health. So I think it's just about holding that in mind all of the time. And that can be really, really hard to remember, where if someone's presenting in a very, very distressed way, or is presenting in a way where you know, where they're engaging in behaviours that could cause them significant harm. It can be really, really hard to remember that actually, underneath that experience is someone who has the capacity for health. So I think the first thing to remember is that, that that's true, but it's the Because it can be really, really easy to forget, and
Aaron Boysen :almost get caught in that cycle of maybe how the patient feels despair and hopelessness and
Jessica Crawley :yeah, absolutely, because, you know, if you think about it, you know, that experience is really, really real for that person. And as dietitians what we can offer, what our role can often be, is going in and taking away the strategy that really looks like it's helping somebody to co but the reason that we do that there's a reason that we think that those strategies, perhaps are not the best ones because they're potentially causing someone significant harm. So I always think, you know, our role is sometimes, you know, if you saw a toddler going up to a plug socket with a fork, you go into intervene, you go into intervene. And, and, but you can really understand why, why that you know why that title had no understanding of the fact that that is potentially going to cause them harm or, you know, are not able to connect with and that because they're so caught up in the moment and so on. I guess something I always hold in mind is that everybody's doing the best they can given the thinking that looks real to them in any given moment. We all are, we're doing the best that we can, considering what looks real to us. And I think it's worth always remembering that we live in separate realities. You know, there, I don't know how many people on earth rather nearly a billion or 8 billion versions of reality. And I think it's really easy to forget that at times, I think it can look like our experience is universal, it can look like we're at the centre of the universe, but actually what we are is we're an individual experience in life in in a very unique way. And, And that, to me is filled with hope and filled with opportunity. Because if my experience is just one experience, and there is, you know, almost 8 billion other experiences, if I'm having an experience right now, that is really awful, really frightening and really terrifying. It must mean that there are other experiences that they're they're out there for me,
Aaron Boysen :even if you think about the variety experiences in within sort of groups of people that have similar issues. So, even like people who live in Leeds, I may have some familiar experiences, but they all have different lives and they all have people who are dieticians. So have different experiences they bring to it. Yeah. And they're helpful to give that sort of different reality perspective from a different reality.
Jessica Crawley :Absolutely. And there are things that universally as a society, we would say, we would perceive as a negative experience or a positive experience, you know, someone who has experienced trauma, for instance, universally trauma is going to be experienced as a negative thing. And, and, of course, we understand that. However, I guess something that's really helped me is to understand that it's not the experience that we're living in the feeling of it's the thinking that we have on the experience. We live in the feeling of our thinking moment to moment, not in the feeling of the things being thought. Yeah, if you want to wrap your head around, I just, yeah, yeah. We we live in the future. feeling of our thinking moment to moment? Not in the feeling of the things being thought, Okay. Just let it wash over you.
Aaron Boysen :Okay. And could you elaborate on that?
Jessica Crawley :Yeah. And so what that means to me is that if you think about what our brains are living in a black box, they don't see anything. You know, the only way that we don't like physically there, yeah, they're living in a black box, they have no idea of the, what the world wants and bones, absolutely, completely starved of light, the completely out of it, you know, they can't see anything. So they're completely dependent on the sensory input that we take in. And then the experience that we have is actually what we project from the inside. It's not what's happening to us from the outside. Everything that happens to us on the outside has to be processed, and experienced through thought.
Aaron Boysen :Yeah.
Jessica Crawley :Does that make sense? Yeah. But it doesn't always look like that. It often looks like we're living in the feeling of our circumstances, not in the feeling of the thinking that we have. On our circumstances, okay, yep. And it is really, really subtle difference.
Aaron Boysen :And it's why someone who experiences exactly the same thing will have a different sort of manifestation of that sort of that experience. So even if you think,
Jessica Crawley :exactly,
Aaron Boysen :I've done that, or I've experienced that, and it can be multiple things in life that can go, I was able to do that, why can't they do that? I was able to do that. Why can't they do that? Yeah, you've got to understand that your thinking is different is different than their thinking the way you were your thinking sort of manifest from that situation is different. And if I'm correct in thinking, it's not always based on previous experiences that have influenced that, so thinking can just be sort of who you are, yeah, your natural sort of,
Jessica Crawley :and the thinking that we get and that's completely unique to us as individuals and that really helps me working in an area like eating disorders, which I often hear that people can find, really you know, it can be combined in a way difficult to understand because it can look really obvious that engaging in a behaviour that is causing to yourself, doesn't make sense. But when you really understand that everybody's doing what makes sense to them, given their thinking in the moment, it just fills you with so much compassion for someone because you really, really start to understand, you know that they're doing the best within the thinking that looks real to them in this moment. Now, that's not to say that we wouldn't go and then and challenge that thinking and offer another perspective, because that's absolutely the role of a dietitian working with eating disorders. It's both being able to immerse yourself in the experience and understand the experience that someone is having, and also help them to see why it needs to be different. So how
Aaron Boysen :does people's thinking and their mental health struggles impact on their sort of day to day life and they're sort of that physical well being?
Jessica Crawley :Yeah. And so if you don't realise that thought is transient, that thought comes and goes without you having to do anything to fix or change it. And you're having thinking that is that feels really distressing. You can understand why people might get really caught up in ways of trying to fix that thinking. So I'll say that again, if you really struggle to see that thoughts come and go, the thoughts create a reality moment to moment, and that we're living in the feeling of our thinking moment to moment. But you know, you know, it's why we can, we've probably all experienced it, where our mind goes completely blank, and we completely lose our train of thought, we've got no idea what we were talking about a minute ago. That's because of the transient nature of thought. Now, if we don't know that that thought is transient, and we're having that an experiences, that is creating feeling that is really, really frightening. We can get really caught up in ways of trying to fix that feeling. And one way that somebody might try and fix that feeling is by changing the way that they interact with food. So it might really look like restricting your food intake or changing your weight or changing how and you know, are changing how you feel in your body will fix the uncomfortable feelings that you're having. Does that make sense?
Aaron Boysen :Yeah. So by controlling something else, yeah, you're able to
Jessica Crawley :manage the energy because of a simple misunderstanding that the thoughts will come and go without you doing anything that that thought is transient by its very existence. But if you don't understand that it can be really, really hard to know. Why does Why does
Aaron Boysen :knowing that thought is trendy and make the thoughts any less distressing. They're gonna go away. But yeah, they still feel pretty sad at the time,
Jessica Crawley :though. No, it doesn't. It doesn't make them feel any less distressing. But it might help you to reduce the fear that the experience is going to be there forever. Because if you think about it, if you've ever been really, really frightened, the fear that that's not going to where does it go away? Sometimes more overwhelming than the fear in the first place.
Aaron Boysen :Is it is it viewed as fixing it or is it viewed as like finding a distraction or
Jessica Crawley :can be a distraction, it can be tick, fixing it can be, you know, I guess people get stuck in roots in their thinking because and because they've they've started to do some thing whether found actually that does that does create a new experience for me. But it's, it's because it but it's the story you're telling yourself about why your experience has changed.
Aaron Boysen :Definitely, we've all had the experience where somebody said something very small or some of these done some very big and yeah, you drive in home and you just, you just post around your head, always, you always work yourself up about the whole thing, and then you reflect on it in sort of a few months time. And you can see the insignificance of that thought, yeah, at the time, it was
Jessica Crawley :all consuming reality in that moment. And so we can really understand how people can then start to have an impact on and by, you know, by getting really stuck with behaviours that are potentially going to cause us harm. So restricting our food intake, potentially using laxatives or vomiting, you know, things that feel like they fixed the feeling in the moment that you can get really stuck in. I guess holding in mind as a dietitian, that those feelings can come and go without using those behaviours and helping people to get through that and to see that can be really, really helpful. Because those those behaviours typically will also come with other symptoms. But you might not be connecting with the symptoms of your experience, if you're just connecting with avoidance of fear.
Aaron Boysen :So just I understand might not be connecting with the, the x what you're doing with the symptoms that you're experiencing if those symptoms are very effectively managing
Jessica Crawley :except something else. Exactly. That's exactly right. And so and that's called a nurse being I guess that's seeing the picture immediately that seeing the picture in the in in the short term that seeing part of the picture. So an example I often use is have you heard of a Newton's cradle? You know, those metal balls that you pull worn in one direction before they come and the energy for reasons cradle? Newton's cradle so that the end of the you know, it comes and you pull in one direction you let it go and the energy passes through the balls and kicks out in the other direction. The further you pull in one direction, the further the kick out in the other direction, will typically speak in someone who's you know, stuck in a behaviour that feels like Working for something, they're not seeing that full picture of the Newton's cradle, they're only seeing half of the picture. So if you think about it, if you think about the Newton's cradle being pulling in one direction, pulling in the direction of restriction, that's going to potentially come with a feeling of being in control. So if you think about pulling in one direction feels like being in turn control, pulling in the direction of restriction, you can really understand or if you're just looking at that side of the picture, how restriction is helping you to feel in control in an otherwise chaotic time. What they might not be seeing is, you know, with everything in there, too, what goes up must come down. So as we start to let go of the pull towards restriction, and that ball starts to fall down, there's going to be a kick back in the other direction, and that's going to feel like being out of control. Okay. So the symptoms are
Aaron Boysen :feeling due to the eating disorder
Jessica Crawley :feels like they're out of control. Now, when you stop restricting, when you let go of the restriction, it goes in the other direction, and things really start to feel out of control. Does that make sense so we can really understand. And this makes sense from a physiology perspective as well. If you think about it, if you think about what might happen if you restrict food intake for a really long time, and eventually, your body's gonna fight back, it's gonna fight back and it's going to send you signals that you really, really want, you know that it really, really needs to eat. So in one, you know, in the pull towards one direction, and the pull towards restriction is going to be a kick back in the opposite direction, which is the urge to eat. Now, if you're frightened of the urge to eat, you're going to feel completely out of control, you can think that by restricting my intake is the only way to avoid feeling out of control with eating. You can see how people get really, really stuck with a behaviour of pulling in one direction towards restriction and by letting go of restriction, feeling really, really out of control and you want
Aaron Boysen :to grab the restriction again and pull it back salutely restrict harder that time. Yeah, more or
Jessica Crawley :exactly cycle and it's like a cycle. Yeah. So you know, the further twice restriction the further the kick back to being out of control, but people don't typically see that. So people don't typically see that the more you're restricting, the more out of control you're going to feel when you're not restricted. So restriction looks like the only option. However, what would happen if the restriction wasn't there in the first place? What would happen to the Newton's cradle?
Aaron Boysen :So, to the analogy, the Newton's cradle the kick back would be non existent
Jessica Crawley :and be non existent things would be still things would be settled. Does that make sense?
Aaron Boysen :Yeah, I see what you're saying. Yeah.
Jessica Crawley :But by having restriction in the first place, that's the only reason that the feeling of being out of control is possible. It's not that the restriction is giving you control don't other things in life,
Aaron Boysen :not just food make you feel out of control?
Jessica Crawley :Yeah, of course they do.
Aaron Boysen :So wouldn't wouldn't that kickbacks exist even if there was no restriction of say food intake and therefore,
Jessica Crawley :potentially, I guess our experience is changing moment to moment, isn't it our experience is changing moment. And like a blood sugar's attention you know, like a hormones change. Moments moment, we have different feeling states every minute of every day. And we have different physiological states every minute of every day. However, we can get really, really stuck in patterns of feeling like we have to do something to have control, if we don't realise that it's the attempt of having control. That's creating the absence of it.
Aaron Boysen :Lots of things in sort of the world push people to view self control as almost like glorified. Yeah. And so there's a big, there's a push at the moment like self development, culture, self, I say self help, but often, it can be like self help, can be sort of self care, but the self help thing you might read a self help book, the best morning routines, get your morning or perfect so you can be ultra as effective as possible. And you might, now that you're saying this, I'm sort of thinking those might be those can also be viewed as an element of restriction and restrictive and a rigid schedule and therefore,
Jessica Crawley :yeah, absolutely. So we get so caught up in doing to manage our experience. That we that we take the beating out of it we take the being out of human being. We take you know, we judge ourselves almost for having a fluctuation in our experience, moment to moment we get so caught up in being productive or having a positive experience. When we have a negative experience, we judge it. But the reality is in order for us to understand what a positive experiences we also have to understand what a negative experiences. Yeah, you can't have one without the other.
Aaron Boysen :Precisely. Yeah, we have to have the negative and the positive.
Jessica Crawley :Yeah, that's just life is all about contrast.
Aaron Boysen :Yeah. And I do think the way people obviously you could sort of pigeonhole social media is one of those things that maybe diet culture, diet culture, by diet culture. What do you mean by that?
Jessica Crawley :Yeah. So what I mean by diet culture is this idea that it's admirable to potentially live in a smaller body or is admirable to be engaging in health behaviours. When I say health I'm using, you know, inverted commas, health behaviours, which mean where we attach the way that we in the way that we move and the way that we engage with them. Life to morality and to moral value. So diet culture, I guess, is pursuing this idea that thinness is healthy. And that changing our eating behaviours are some way attached to our moral value that we're not as valid or that we have some willpower issue or there's something fundamentally wrong with us if we don't eat in a certain way or exercise in a certain way or live in a certain body. And diet culture really perpetuates this idea of the thin ideal and this idea that we have to be and look and eat and exercise in a certain way to be valid members of society. But of course, we know that's not true, because we're all different. You know, we're all different expressions of life and
Aaron Boysen :feel like that's, that's always been a sort of an underpinning current, like, even when I was in primary school, I didn't get the right lunch. I didn't look like everyone else's. And it's sort of like, but it was it sort of magnified and diet culture, like you've got to have a certain type of food or that kind of thing. It's almost like an extension of that, would you
Jessica Crawley :it means something absolutely. It means something about you who you are in By the way that you eat, but you know, and it's a really successful model, isn't it? It's a really successful model in generating money, but it's probably not a successful model in promoting mental health and mental well being and, and this idea that you are enough, you have always been enough, you are everything that you need, you know, what can I sell you if you believe that you everything, you've already got everything that you need?
Aaron Boysen :Even, um, even look at this equipment, I mean, I probably didn't need it. And it's definitely an element of someone showed me and go, you can produce the best podcast ever. If only you have this answer. I mean, definitely fall into it myself in certain aspects. And I think we all all do nothing. Of course
Jessica Crawley :we do. And it's just about being kind to yourself along the way, isn't it? You know, we're all having a human experience. We're all doing the best we can, considering the thinking that looks real to us. But it might also be possible to have a different experience from the experience that we're having right now, if we can open up our mind to different possibilities.
Aaron Boysen :So when I think about lots people will be listening to this podcast and they won't be eating disorders and dietitians Many people with eating disorders or they won't be really drawn to the area, not saying they will never be but as of yet, but in their daily job or daily sort of routine or the patients they see they might see patients with eating disorders. And sometimes that can be fear or anxiety or with all healthcare professionals about how to talk or how to communicate with them. Someone with the eating disorders, yeah. Is there any sort of, is there anything we should be careful of, or any sort of rules of thumb you would suggest that we follow?
Jessica Crawley :Okay, so first of all, I just want to say how grateful I am to everyone out there in an acute hospital who supports the management of anyone who is really struggling with an eating disorder. And you know, because you're keeping people alive, so thank you. The fact that you claim that and the development of marzipan guidelines, which is the management of really sick patients with anorexia nervosa was developed over Use the risk of not you know, the risk of death when people with anorexia were admitted to hospital. And luckily we've we've got some really fantastic hospitals are on board with that and dieticians playing a really integral role in that. So, first of all, I just wanted to sound you know, on behalf of Connect, we're really grateful for the support that we have from our key partners, but completely understand the fear and the anxiety that can be associated with that. So the first thing that I would want to say to anyone who's you know, who's working with someone with an eating disorder, who doesn't feel like they're a specialist in the area is you are a specialist in nutritional assessment, you hire a specialist in understanding the impacts of starvation on the body, and your inset your assessment will be able to inform you of that. So no matter what the person who is saying in front of you, you are in a position to really be able to know the risks that are presented and and the impact that stablish and is having on that person. And therefore you also know a solution to that. And which is to help someone to you know, to meet their nutritional needs, even when they really really cannot see that that is a priority for them. So the first thing I would say is trust your assessment, trust that, you know, trust that you absolutely know. And then you know, the nutritional needs of that person. And even if it really, really vastly differs from what they believe that their nutritional needs are in that moment. And then also, you know, don't be frightened to understand what their experience is, don't be frightened to really understand what it Why is that they feel so frightened, and really validate that really validate that you understand that someone is feeling really, really frightened of their experience right now. Because by really, really understanding their experience, you'll be able to show compassion for them. And really, really understanding the fear that comes with doing something different, you know, they're really, really see that you care. But also holding in mind that something does need to be different, because if they continue as they are, there's a really, really high risk associated with that. So it's about holding the two mindsets in place. Number one being able to hold in mind. I'm really, really sorry that you're having such a frightening experience right now. And I really, really need to be able to support you to do something different in order for you to manage your health safely. So that's the first I would suggest, you know, trust your assessment and, and hold the two perspectives in mind and never forget the fact that improve nutrition is what's going to be required for that person. The other thing I would say is, you know, seek support if you're struggling if you're struggling with knowing how to implement and implement something different so seek Six Apart from your local eating disorder unit or you live at a local eating disorder service if that's available, Six Apart from your local eating disorders, dietitian and seek support from you lately as in psychiatry team, and really make sure that you've got a team around you that is there in the best position to support that person so might be a gastro team leaders and psychiatry team. And it might be some input from the specialties and disorders unit. And, and then I think, you know, this fear of saying the wrong thing. That often comes from failing to see someone's resilience. If I say the wrong thing, I'm going to create pain or harm or potentially, you know, make the situation Worth, I'm not sure that as human beings, we can do that. I think that what we, you know, I think what we can do is just really accept our humaneness and say, the way that I'm seeing this might be different from the way that you're hearing this. And I really want to explore that with you. And I'm really, really sorry, if perceive something that I've said in a way that I haven't meant it. Because by being open to the idea that you can work through effectively how somebody might be perceiving something, you get less frightened of saying the wrong thing, because it was so frightened of saying the wrong thing, we might not say what we need to say we might not be able to put in the interventions that that person needs. And actually what we really want to avoid is underfeeding. And, and and not managing that the acute risk that's in front of us. And so if we're too frightened of saying the wrong thing, we might not say the thing that needs say,
Aaron Boysen :you might view patients with eating disorders or experiencing eating disorders, slightly more. And it may be stigma this involved in this sort of thinking but slightly more sensitive. They've got More sort of not understanding their resilience and almost giving them more sensitive role than they actually could have.
Jessica Crawley :Yeah. So it's about holding those both things in mind, isn't it validating someone's experience and really caring that you and being really sorry that they're having a frightening experience, and being able to say what it is that you need to do? Because if the way that you help someone to manage their emotions is by not doing what it is that they need to do, you know, better than the eating disorder?
Aaron Boysen :Yeah, yeah. Yeah.
Jessica Crawley :So, and I guess it's That's why, you know, this is where I talked about, you know, do you really see that person's health? Do you see that they're having an experience of mental illness have an experience of distress, but underneath all of that is someone with the capacity for mental resilience and mental health? You know, if it wasn't for their experience? Yeah, I use the analogy of a snow globe all of the time. And if you think about the mind being like a snow globe, when it's really, really, really shaken up, it's really really difficult to see the picture at the centre of it. So that picture at the centre of it and being The person is being you know who the pit and the snow being, the experience that they're having. And but what happens with the snow globe when we when we continue to shake it well, we struggle to see what's at the centre of it all. But what happens when we leave it alone and give it a chance to settle? Well, things start to come clear again. And that's the that's how the human mind works that when we can leave our thinking alone when we can experience our thinking without judgement. And we can start to trust the transient nature of it without meddling with it and trying to get caught up in things that fix it. We always settle back to having clarity in our mind. And that's true for anyone, even in the middle of having a mental illness, that experience right now will not be permanent, and that they can always come back down at any given moment to a place of mental well being. And so holding that in mind can be really, really helpful. Because it helps you to see that when they're in the midst of a distressing experience and it really looks like you need to get involved in helping them to fix their distress. You don't need to fix the distress it will settle on its own and you know And actually by fixing their distress, if that means continuing to collude with their eating disorder and not do what needs to be done, we're continuing to shake up the snowglobe. So I guess what I'm saying is it's knowing that even if someone's having a really, really distressing experience, or someone's, you know, has had really, really awful experiences in their past, they still have the capacity for mental health, they still have the capacity for mental well being underneath that experience. And, and holding that in mind can be really, really helpful because they might not see that they might not see their resilience, but by using their resilience, it will really help you to hold her that experience can change.
Aaron Boysen :When we think about dietetics in a whole. One thing that's come come about around recently is the nutrition care process. And it's as we discussed before, a bit bit a bit about the assessment. And you taken anthropology, biochemistry, the ABCD format, and when we think about The nutritional assessment Yeah. It's a standardised thing that dieticians use based on sort of, we formulate a plan for what was the name? How does that work within sort of a eating disorder services? it?
Jessica Crawley :I think the first thing to acknowledge is that as dietitians, we are absolutely brilliant problem solvers. Typically, we're very action, but we often have very action based tendencies, we can see solutions, and lots of our interventions are action based. So even if it's something as simple as, you know, stats, health monitor, and that's an action based goal, that we're we're trying to get someone
Aaron Boysen :to the point I think that's unique to dieticians, or is it part of like the medical?
Jessica Crawley :Yeah, maybe. I mean, I guess I'm speaking as a dietitian, who's someone who works with dietitians and someone who works with other allied health professionals quite regularly. I do think that we do that a lot as a profession. I imagine other professions do it as allied health professionals
Aaron Boysen :or just dieticians in general? I don't know. I think we're all susceptible to it. I think
Jessica Crawley :dietitians Some are susceptible to If you think so yeah, I think we I think we typically are, you know,
Aaron Boysen :as we said, that's based on your lived
Jessica Crawley :experience, I think that, you know, we're very problem solution focused, and which is a really useful thing. It's really, really, it's great. But sometimes, that can mean that we are not always comfortable sitting in the land of the unknown, and they're not doing
Aaron Boysen :like a movie that you don't know the ending to cause more anxiety than actually knowing the ending.
Jessica Crawley :Absolutely. And so I think it's just worth acknowledging that that, you know, much of our training, our assessment of, you know, everything that you've just talked about is all about focusing on actions at the end of it. Now, the person in front of you might not even have contemplated the idea that they're ready for change yet. And I suppose as part of the process, we're really hoping we're hoping that we can, that we can help somebody to get to the stage of wanting to put actions in place, however, and it might be that a good outcome from your intervention. Helping someone to move from not knowing that change is even required to contemplate in the idea that change is possible. And that's quite different from getting someone to the point of doing something different. contemplating that something can be different is a step in the change cycle.
Aaron Boysen :I think sometimes we services, we might put certain barriers in the way like, opt in letters, call this number on this day, yeah, jump through this hoop to get this appointment to show that you're really willing to go for it. Yeah. And yeah, making sure they're ready to commit to goals as soon as they step in the appointment with you.
Jessica Crawley :But just because someone steps into your appointment doesn't mean that they're ready for change. Because you don't we don't always know the 100% reason that someone is presenting in front of us. You know, we might be shame and guilt that's brought someone in front of you. And by jumping into action based tendencies, you might be perpetuating the shame and guilt idea. If you really haven't spent some time understanding why someone is there, what their agenda is, and if they're even in a position where they want the agenda that you can offer to to marry up with So I really, I guess your question was, do we follow the same process? Yes, we do is the answer. Yes, we do. We follow the same process of assessment. And we and we typically would hopefully be helping somebody to get to the point where they can change and change, change something that they're experiencing that potentially is causing them harm. However, I guess what's slightly different in a mental health setting is that there might not always be action based tendencies at the end of it, it might and it might be a longer process before before somebody gets to the point of, of changing their behaviour. And actually, you might really pitch you intervention in helping someone to go from not contemplating that anything can be different to just contemplating that something can be different, and that would be a good outcome of that intervention. We do practice in the same way as other dieticians. But I think we just pay attention to where is that person in their change cycle and how can we pitch the intervention and to meet them where they're at? And actually, this is where our own feelings and becoming reflective practitioners comes in. Super, super helpful because If you notice that you have a feeling of frustration, for instance, that's coming up in a consultation or a feeling of and a mismatch between your expectations and the clients expectations. What a wonderful warning signal What a wonderful clue that your body's giving you, that you perhaps not listening, the perhaps not meeting them where they're at, as opposed to it being a warning signal that it's something wrong with how they're interpreting your care. So I think that what we can always do as data is is work really, really hard to understand what it is that that person in front of us needs from us and use our own feelings as a warning signs, whether we're, whether we're we're listening to them, and because if we are feeling frustrated and feeling like somebody's not responding to our intervention, the chances are is that we're not listening to them. It's not that they're not listening towards, if that
Aaron Boysen :makes sense. to them. That's always the case.
Jessica Crawley :And well,
Aaron Boysen :I suppose they might not want to listen to
Jessica Crawley :the man even be in a position where listening looks like a choice. Okay? So keep that in mind. I can think of as many examples. One example might be, you know, if you've got someone with really poor wound healing, who can sit and they're having really poor nutritional intake, and there you've gone in and you've put in multiple interventions to help them to improve the nutritional intake to improve their wound healing, but they're really struggling to implement them. You might get, you know, you might, it might feel frustrating, but you can see a solution to a problem and the person is feeling unable to take that solution. But have you really, really explored whether or not improving their wound healing is on their agenda? Or if they even understand the link between improving their nutrition and their wound healing? Or are they struggling to listen to you at all in that consultation because they're in so much pain, so rarely Are you better off going back and doing that intervention when someone's pain management is well underway? When someone has, you know, looked at other other strategies that might be able to reduce risk in the first place or they had a medication review or have they been mobilised and, you know, just Is this something that would come before they even being on their radar that changing their nutrition, nutritional status is going to improve the symptoms? Does that make sense?
Aaron Boysen :That does make sense. I'm gonna I'm gonna give you another example, I think might be a little bit more, say a patient who's on dialysis as a high potassium, but quite openly will drink orange juice says I've been told not to drink orange juice, but I just don't care. I just want to drink orange juice. I like orange juice. What does it matter? Yeah. And you might sort of be able to explain to him or her Yeah, about the consequences of drinking all this. Let's just say two litres of orange juice today. What is happening, the acute complications that could cause behaviours goes, I just don't care. Yeah, not bothered. And now you could listen to that. And you could understand that he probably actually doesn't want to change. He's not in that place of the change cycle. Yeah. Potassium is high. Yeah. And we want to get it down. Yeah. So that can often I'm actually getting frustrated.
Jessica Crawley :The first step is Yes, sir, isn't it so tell? You're number one, I guess you think we can't create change in any one change only happens in people, it might look like we can facilitate change. But actually change can only happen by somebody having fresh thinking and seeing something from another perspective. Now, knowledge doesn't equal understanding. So someone might have the knowledge that an orange that their orange juice is going to put the potassium, but they might not really understand what that's going to be like, from an experience perspective from them. You know, we can intellectually understand some that know something, but not understand it.
Aaron Boysen :So to say we need to teach some better or,
Jessica Crawley :again, not. I
Aaron Boysen :feel like it's gonna get in a massive cycle. You can't just beat yourself up and go, I'm not teaching the best I need to be better. I need to be always better. Like I just feel like it's going to go on to spiralling down a cycle of just if
Jessica Crawley :you think it's your responsibility to create change in that person. Yeah, absolutely. But there's only so there's only so much we can do. There's only so much we can do.
Aaron Boysen :Is it not natural to feel an element of frustration like, God?
Jessica Crawley :Yeah, I'm not saying GG frustration in any way, shape, or form. I mean, I would I would share the dilemma often, I would share the dilemma with that person, I would, you know, but and I wouldn't do it myself, am I really understanding their experience right now? Because when they say, I'm really not bothered, I'm not bothered? Do we know why do we have a real understanding of that? And are we willing to really sit and understand and validate that person's experience with them? And are we also able to think about offering them another perspective of why why it's important without it being symptom focused or action based, you know, there's a lot of conversation that you could have with that person who saying, Yeah, I understand that, but I don't care. And it's not all going to be in the direction of why you should care and you need to change your behaviour, because I'm really worried about you. And but but the reality is, we can't Yeah, we can't create change in people we can, we can offer people the opportunity to make an informed choice, and we can try and reduce harm. And yet we can get frustrated because we care about people, that's fine, but there's no harm in telling them that either.
Aaron Boysen :So obviously, you've got a wealth of knowledge of all Different areas and things. Is there anything? If there's any sort of any people listening? I've gone. Wow, that's really interesting. I'm really interested in that area. Is there any sort of recommended reading or any things you would suggest for them to go? Yeah, further look at or
Jessica Crawley :I think some of the things that really helped me a lot of the understandings that I've shared about how the mind works and how thought is transient and where our experience comes from, that came from an understanding of a philosopher, called Sidney banks, and he wrote some books, and I guess putting into putting this understanding into words. And the enlightened gardener is one of his books. And the missing link is another of his books. And I also read a Michael Neal book called the inside out revolution. And there's another book from Dr. Amy Johnson, who's a psychologist who used to have an eating disorder, and called the little bit the little book of big change. I found those really, really helpful in helping me to see people's health. And a really interesting book is also called recovery from within and that's a mother and daughter who have written that book about their experience. If someone's recovery from and mother and daughters relationship and whilst the daughter was recovering from anorexia and and that talks about, you know how full recovery is a possibility for absolutely anyone. So those are those are books I found really, really helpful in terms of giving me the confidence to and birth whole compassion for people and feel able to challenge people's thinking. And because I understand because it's helped me to have an understanding about how thought works, and from a from an interest from a dietetic perspective, and there's some really amazing podcasts out there from from dieticians, who talk about diet culture and about our role as dietitians in creating change with people and how sometimes if we're too action focused, we can probably perpetuate feelings of shame and guilt. And so Fiona Sutherland is one of those dietitians she's got I think she's a podcast is the same as her Instagram title. She's called the mindful dietitian. And there's also a book on intuitive eating. And I forgotten who wrote it
Aaron Boysen :was the one written by dieticians in America. Yeah, I'm written
Jessica Crawley :the original Evelyn Tribble Evelyn drivel. Yeah. Evelyn Tribble. I think that that's, I think her book is great in just in terms of understanding and inevitability to feed ourselves and how our social conditioning and the way that we learn stories about ourselves and stories about food can change the way that we interact with food. So that that'd be the direction that I would start off in. And then I would always just invite you to connect with dieticians who are out there. So I guess our service is called Connect, because we're really really interested in helping people to come together around people living with eating difficulties and think about how we can support them so and you know, connect up with you locally in disorder services, ask if you want to go and shadow and yeah, I'll go on some training different universities offer training and So yeah, just just follow your nudges, follow up what appeals to you follow what makes sense to you, and, and any resistance that you feel coming up any uncertainty or any feelings that feel uncomfortable for you just really lean into them and try to understand where they're coming from and see if there's anyone that can support you with that. who's who's local to you.
Aaron Boysen :Thank you. Thank you very much. That's a wrap.
Jessica Crawley :Yeah. Hey, thank you very much. It's been great to be part of it.
Aaron Boysen :Thanks for joining me this week on dietetics digest, make sure to visit my website a dietetics digest comm where you can listen to the podcast, want to consider subscribing on Apple podcasts, Stitcher, smart radio, Spotify, or basically just ask Alexa, and you'll never miss a show. And while you're at it, if you found this show valuable, you could do one of two things. Firstly, you could leave a review on the podcast that you're listening to the Apple podcast or Stitcher smart radio. And if you could tell a friend about the podcast, that'd be really helpful. help grow the podcast. Thank you so much for the support and have a lovely week day wherever you are.