Centering Mothers, Not Providers

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Transcript

Lindsey: Rebeca, what a pleasure to have you on the OTs for Public Health podcast again. I'm so happy to have this time that we can spend together. 

Rebeca: I agree, Every single time I'm with you, Lindsey, I'm just really just blown away and I'm reflecting on our conversations and it's just a fun time. Thank you for having me again.

Lindsey: Oh, it's such a pleasure, such a pleasure.  I am excited to have you on specifically today because there was a really interesting panel discussion that happened just last week, and it was born out of a question that I think we hear pretty constantly from healthcare leaders, physicians, and even within our own rehab community. And that question is among many, do mothers really need both an occupational and a physical therapist? What's the difference? And are we duplicating services? And I think as we've been building maternal rehab programs, thanks to so much of the work you and Jenna do across different settings from acute care to home health, to telehealth, these questions really do keep coming up. Hospital administrators really want to know if they're over-utilizing resources. OBGYNs and midwives really want clear guidance on when to refer. And frankly, even our rehab providers aren't always sure, how to what makes our approaches different and complimentary. So I think we've learned that this isn't really always a conversation about professional territories or even scope of practice. It's about, to me, a healthcare system that's failing mothers at an alarming rate. I think you said in the panel discussion, 80% of maternal deaths being preventable and asking ourselves whether or not we're going to center our discussions around provider convenience or client needs. And so this most recent panel that you brought together, Rebeca, were comprised of two amazing occupational therapists and you and Jenna, two physical therapists working at every level of care to really address these questions head on. It wasn't defensive. It was beautifully collaborative. And I think this is because we're really facing a maternal mortality crisis with massive gaps in postpartum care access. And so to me, very often the question isn't whether we need OTs and PTs. It's how we can all work together to serve this population where we currently are. So thank you for continuing to bring these questions up because things need to change.

Rebeca: I agree. This one was a bit of, I feel like almost a homecoming. I think this is now an annual thing we're going to do is we're going to get together just experts across the field and have these open discussions. One thing that didn't come up in the panel, and actually I watched the playback and I realized where I edited it out because I was at that moment going to share that Jenna and I, it was around the topic of the 80% of maternal mortality rates. And Ivey really brought that up. Ivey Verasalo, one of the occupational therapists on the panel.

And at that moment, I just decided I'm going to pivot just for this because there's another moment to talk about that. And so just something of just your opening, your intro and your introduction to this topic, it just made me think, well, maybe now is the time to just kind of just be real with people that I'm still very much in mourning. My dear family member just lost her life just recently after complications after a cesarean delivery.

And she was in her second year as a mom and just suffered a brainstem stroke. And that was from just uncontrolled hypertension, preeclampsia that never went away. So in terms of birth recovery and postpartum recovery, I'm starting to think now recently with attending her funeral and being with our family, that we're talking about postpartum recovery as this thing that has an end date somewhere.

But we've defined that end date as what? Is it the first three months? Is it six months? Is it 12 months? When is the end date for those people? And in her case, we didn't ask enough questions. She actually got OT and PT after the fact, after her brainstem stroke, was in rehab. And then she, unfortunately, just to our shock, succumbed to cardiac arrest.

And I remember the day she went home, I got a call from my nephew four o'clock in the morning. And he said, Nicole almost pulled the baby down with the bassinet. The newborn, their newborn, almost fell to the floor. She was trying to get up to go to the bathroom. And she was lying on a couch. That's where she was resting after her C-section.

And in the hospital, I know I'd advocate, I called every day. I'm like, get a physical therapist, get an occupational therapist in there. Get someone. At that point, I didn't even care. I'm like, get someone in the room so that they can do way thorough of an eval than their nurses were going to do, than the doctors were doing. Because no one was aware of the fact, except I think for me, that she was using the hospital bed as an assistive device.

That was her DME. That was her assistive device. And we sent her home without an assistive device.

And here she is trying to use her bassinet. And so when I now talk on these panels and get these people together to talk about the differences between OT and PT, I've realized what the issue was with Nicole is the issue that plagues us today as rehab therapists is we're trying to make so many decisions without going into the room. We're literally having these conversations and we haven't even stepped into that person's world to understand their context. 

Why would I say as a physical therapist, I'm the only one needed on the team to practice log roll or incision protection. And I don't even know this person doesn't have a bed to go home to. They're going home to a couch. 

And I'm not understanding the context of their day and the interactions with the people that they're going to be with. And maybe even their understanding of the medications that they have to manage or the home management aspect of their experience and their recovery. I'm not doing all of that.

I'm only focused on the movement. I'm only focused on maybe the vital sign response to activity. I'm maybe only focused on what do they need to get them home. And I'm forgetting there's this whole person. And so I'm trying to make these decisions before I even step into the room. And I only have so much time.

And I'm like, you guys can't do that. I'm sorry. We don't do that for anyone. Anyone who's had a stroke, a spinal cord injury, a brain injury, a knee replacement, a shoulder replacement, a back injury, a concussion. Whatever it is, we would never make those decisions without actually speaking to the person, doing an evaluation, and understanding there is a bigger context here. We need both people.

We need a bigger team than ourselves. And I think that's where I'm really getting with the maternal population is that this is actually not a population that's treated as a body part. We're seeing an intersection with neurologic impairments, with cardiopulmonary impairments, with mental health impairments, with maybe a baby in the NICU, with social determinants of health.

We're seeing all of these things intersect. And we're trying to just put one of our disciplines in, PT or OT. That just doesn't make sense to me. There's this whole person, and this whole environment that they're interacting with. And I'm taking this just personally because Nicole was 34 when she died right?.

Lindsey: Kelsey Mathias, one of your panelists, along with Ide, actually had a quote that I think speaks so much to what you said. And I scribbled it down here. So I'm going to read it as to do her quote and what Kelsey said was, it has been so provider focused instead of client focused that sometimes this conversation can be frustrating to me and me because we're centering the experience of the provider, which is not what healthcare is supposed to be. We're supposed to be centering the experience of the person in front of us. 

Rebeca: Kelsey, I had her on the panel last year. We did a bigger discussion around OTs and PTs and pelvic health. And the amount of wisdom that she drops just from her lens of practice is more population health.

I mean, it's no longer just individualized provider or even systems-based care, like what's going on in that particular setting, hospital or home or whatever it is. She's really thinking of a population as a whole. And so when she said that, it just resonated so much, I think, with all of our frustrations that we're seeing maternal health, morbidity, and mortality rates really so deplorable in this country because I think we are focused so much on what the provider factors are, even down to how someone is positioned for labor and delivery.

I mean, if we were really to be honest, that's provider-led in terms of how that person is positioned. And I led a panel of OTs and PTs. I believe it was even patients.

We did a birth experience panel that was led by an OT, Marlee Sizzler, now Dr. Marlee Sizzler, but she was doing her capstone, if you will. And we had one of the physical therapists who was just talking about her own experience and saying that her arm was held down during labor and delivery. And she could feel the pain from the stitches, from her perineal tear.

And I'm just, I think that some of these conversations have just been so traumatic in nature because we are dealing with a population where so much of the focus is actually not on them and their experience, but it's on the provider. And so when I think of OTs and PTs, just asking the questions, well, what's the differences? What's our role? Is there over-utilization of our services? All of that. I have to just go back.

Have you even talked to this person? Have you gotten a sense just from your observation? Have you actually been on the unit? Have you observed labor and delivery care? Have you observed nurses? Have you observed how much truly is maybe burdened by the nurses to understand the patient's experience before you're starting to kind of build your practice and build your program and make these decisions that are really not in the interest of the person? And you think that they are. I mean, these are people, these are our colleagues that we're talking about, Lindsey. We're talking about our OT and PT colleagues who from their heart of hearts, I trust that they mean well.

They're trying not to burden this person's insurance or whatever it is. And I get that, but I don't know that they're really giving themselves enough chance to really understand that patient's experience to then even put so much on themselves as a provider to try to address all of it when they know they won't. Like I know as a PT that I would probably not guide someone in medication management, in time and scheduling management, in setting up meal trains.

These are all the things that Kelsey was talking about. Like, I mean, just like after that statement that she just made about provider focus, and then she gave just this amazing example towards the end of the panel discussion of what would an OT do or what would they focus on that's different than the PT? I put a check nest to everything that she mentioned because I said, yeah, I don't do that. I don't focus on that.

And that's not a mark against me. It's just in my attention, when I'm addressing the things that I see and have evaluated, those are just not on my radar. Like it would be with an occupational therapist practitioner. 

We just have to recognize that. And we have to realize that a lot of what we're addressing are the needs of the person in front of us, not our own preferences as providers.

Lindsey: And I wonder if we think about this, Rebeca, because there's a lot of things that are out of our control as rehab providers, potentially taking things up with their, quote unquote, being duplication of services on the hospital administrator level.

Maybe that's something we wouldn't imagine doing in the course of our work week, or maybe it seems intimidating, or we're not even sure who we would talk to. But I think something that we can agree on is that we're interacting with, as an OT, with my PT counterpart, as a PT interacting with my OT counterpart every single day. Are there things we can do to stop thinking about it as maybe the perceived turf war that some people think that it is, and to refocus and recalibrate on why we got into healthcare to begin with, which is to put ourselves in the shoes of the client that we're serving, and kind of get to know each other's zones of geniuses. When Kelsey mentioned that at the end of the panel, and you were like, yeah, I'm not doing those things, and those things sound amazing. Equal respect back to the work that you would do that I also as an OT wouldn't do. Are there things that we can do right now as people listening to our discussion, boots on the ground, being able to look at our PT or OT counterparts in the eyes, and how can we get past thinking about this in that sort of divided turf war status that it sometimes can take on? 

Rebeca: Yeah, I mean, I think it just begins with case studies. I mean, Lindsey, going even back to early clinical practice, did we not learn in our courses? I hope that we did. I hope that we just didn't show up in a course and just learn the skills without the story. I should say that, not just across pelvic health, but I would say in both of our disciplines, did we not learn about people's healthcare journey from start to finish by stories? I think we've almost lost the art of storytelling in our journal clubs, especially if they're multidisciplinary.

And some hospitals still really do fight to have those, lunch and learns, anything like that, where you can even do dialogues like we had with the panel discussion in an open forum, inviting maybe other colleagues from other hospital systems, if that's the settings that you work in or across other disciplines, it's just more dialogue. And I'm not talking about like the podcast where I just hit record and I just start talking to the air or someone who's in my discipline, but I'm talking about interdisciplinary, multidisciplinary discussions around a case, mini grand rounds that actually allow both parties or multiple disciplines to really dissect that case and tell the other what they would bring to the table. And I might, as a PT, be focusing on something in particular, but really just addressing the sensation that that person is experiencing, whether it was an injury at the time of delivery, with the malpositioning, an epidural related injury, if they experienced pain during their surgery, whatever it is, and looking at their mobility, their transfers, their strength, their balance, their ability to carry their baby.

And then I have an OT colleague that is also then looking at the person's experience, maybe how they're now processing the experience that they had and how they can modify, not just themselves, which we really focus on modifying the body, the positioning, the equipment, but modifying the environment to fit them. Where is their social support? Who is going to be there to organize this? What is that environment that's going to look like that they're going to interact with? And just having that case and being able to talk through it like we did on the panel. We did that one or two times. 

I think that is a lost art, I think. We're making a lot of decisions and we're not taking real people, real cases, and really matching real solutions to those. We're really making these programs based on an ideal and making huge decisions that will impact someone's life before we actually get our feet wet, get in there, make mistakes.

And I think that really is a scary future because we're already seeing if the maternal mortality rate is 80% of the deaths are preventable, but we're still doing the same thing, that's insanity. And making decisions without involving a person, a real person, to me is a for a disaster. So I think that it is a turf war because we're trying to fit this ideal, which is offering our services, being part of a team, rehab, being integrated into maternal care. We're trying to fit that ideal, Lindsey, into the current system and that just doesn't work. You can't change a system like that. You really have to build something new.

And I think building something new is going to take both disciplines having the opportunity to interact with this patient population and then come up with their plan of cares and then look at it at that point. You have to have both disciplines involved to then say what would be the ideal from there. 

Lindsey: I love everything that you said. The thing that particularly resonated with me is this idea of not just focusing on skills, but stories. And I think that humanizes it. And it also just helps us bring a deep respect for literally the day in and day out that we bring to the table together that really so much enhances our deep understanding of the skill set that we're both bringing that that client so desperately needs.

That was really beautiful, Rebeca. One of the other key topics that I think was focused on in that panel discussion was telehealth. And I know that the panelists were very passionate about telehealth access. There seemed to be a little bit of frustration regarding dismissing telehealth as a gold standard of sorts. And I'm curious as to what you think the conclusion was on that and how you might respond to colleagues who maybe maintain that position. 

Rebeca: I mean, I was one of those colleagues, Lindsey. I mean, I almost wonder, I do wonder. I wonder if my earlier practice added to the problem because I was residency trained as a physical therapist in women's health. And at Duke, there was this almost like this culture that we are holding kind of the, we're creating a standard, right? And a lot of my early recovery ideas really came from that residency.

I mean, there was a lot of good there. Like we, like I was actually pretty shocked to then practice in rural North Carolina away from Duke and just see patients being referred months later, you know, after just surgeries, surgeries that I say, man, we saw within three days after a mastectomy at Duke and it'd be three months with radiation, fibrosis, lymphedema. I mean, it was just horrible.

But even then, you know, I thought that we were still ahead of the curve because OTs and PTs were both on that team, the women's health team treating that patient population. So I really did elevate in-person care a lot from just the experience I had with women's health rehab is that that was truly the gold standard. Like, you know, what you can see, what you could feel, all of it. And then it was slowly where I just started to encounter more patients who they did not have access to that standard. They did not have access to a person. My first patient that I actually really was involved with was a woman, rural South.

It was months before she was going to be able to see a pelvic health therapist. It's incredible. It was a two and a half hour drive for her, but she had just suffered a miscarriage, a late miscarriage in her second trimester. And she was just having like pelvic organ prolapse symptoms and things like that. Just pelvic floor dysfunction, all of it. And I remember like doing this virtually with her thinking, this is substandard.

I can't see you. I can't see what I'm doing, all of it.And really not even at that time thinking within her context of how grateful she was. I mean, I would just get thanked all the time. Like she was just so thankful that I'd be available to talk to her, available to guide her, show her things, have the camera set up at all.

You know, this was way back in 2021. I just remember doing this and I'm just like, this is not ideal. But now looking back at that for her, the gold standard in my current director that I'm working with now at Origins said this beautifully over the virtual health team.

Andrea said recently that the gold standard is patient-centered care. And I realized that's it. I think I was missing the boat. And in this panel discussion, it came up again. Ivey really brought this home to me when she was just talking about access issues in Texas where she was. And it just made me just recall and just think back to that patient and then the patients I'm now treating with Origin and working with them.

And I just realized I needed to immerse myself in this setting to appreciate how valuable of a setting it was that I was mistaken. And I say that publicly now, Lindsey, I made a mistake. I considered gold standard care as the setting and not the focus on the actual patient. Like what in that moment, regardless of setting, were we doing? We were prioritizing early intervention for that patient and in their time of need. We weren't waiting months at a time to offer them gold standard care because at that point, that would be subpar. If it were in-person pelvic health for that patient and they had to wait, that would have been subpar.

The gold standard was actually centering that patient within their environment, within their context of whatever they're able to either achieve or access, and then centering and prioritizing what we could do in that moment. Not saying I can do everything because that's also not gold standard. Having a therapist say, I can just achieve everything.

I'm the sole provider, which we heard before. And it's really sad that that's the message that some therapists are getting is that pelvic health physical therapy alone is you could provide the gold standard of care. You cannot. There's no one discipline that can do that for a person. We're not even meant to do that. We're supposed to center people as the drivers of their care and be their guide.

And so, completely, when we were able to actually dissect the conversation around telehealth, Ivy and Kelsey, to me, were just the cream of the crop in terms of their approach to it, that this is really centered on the person. And telehealth or virtual care is just another setting that allows us the opportunity to engage with that person. 

Lindsey: Really what you're describing, Rebeca, is a transformation or maybe even a maturity as we are in our occupation, our profession, which is starting off with those skills that you talked about, sort of that theory, that idea that has been passed down to us, either through the program at Duke that you were at or through our graduate studies.

But when we're able to take a step back and ask ourselves, what is all this for? Are we doing this so that we feel like we're providing the end-all, be-all, the best version that we read about in a textbook or maybe was passed down to us in some sort of field work? Or are we actually going, no, the best practice is exactly what you said, client-centered care, the stories. And so it's like, again, this is the theme. This is now the second time this has come up in this conversation, which is at the end of the day, what does the client need? And I think that also centers us and calibrates us as practitioners to always focus on what actually really matters, why we got into this field to begin with, and to just uphold the ultimate respect for what that client needs, regardless of the discipline, the vehicle, the setting, how it's delivered.

Always kind of coming back to that. And it really, even as I think about it, it cuts down so much noise. I feel my shoulders drop with the ease that that puts in my body because, yeah, that's why we got called to be in these fields to begin with. So, I so appreciate this sort of call back to that sort of true nature and how it meets maturity as well. Because when we all graduated and got out of school, and even picturing you in your residency, it was like, oh, I want to do right by all of my mentors, by the program that I graduated from. And that is a beautiful feeling.

But then let's kind of soften that a little bit and meet the story there that calls us to serve and show up in the best possible way in the way that that client needs us to do. 

Rebeca: Yeah. And also as cultural humility, I'm kind of like just inspired from an interview I did with Dr. Arame Ambarizade. I mean, I was just sitting next to this amazing person, president of AOTA. And here she's teaching me about cultural humility. And I'm kind of just stunned because I don't think I've ever really understood that term. Like I was trained as a physical therapist and cultural competence. And it truly felt like a checkbox class. Like, yes, I'm now competent.

You know? And she just completely like flattened that. Like how can you actually be competent in someone's culture? And I realize I have been approaching my career with that checkbox mentality. Like if I do this, this, and this, and this, and I meet the standard of care, and I've assessed all these things, and I can provide this beautiful plan of care, and I'm checking all the box, it just puts so much stress on me.

And I mean, you know the energy that we carry, especially, I mean, with this recent panel discussion, it's about internal health. You bring that kind of energy into the room with you, that person's going to feel it. They're so, you know, their sensation, their senses are so heightened.

And I just, I think really back to that, like what are we actually talking about when we talk about gold standard? And Kelsey shared something on the panel that I was not expecting her to share. And I didn't really get a chance to respond to it in the moment, but she was talking about the internal pelvic floor exam. And how the first time she had that performed on her, it was at a Herman and Wallace course.

And she, you know, peed right there on the table. And she said, was that an accurate assessment of my pelvic floor? And Lindsey, when she said that, I had a flashback. When I was in my residency, I, you know, eager resident, wanted to please everyone, was the volunteer for a pelvic health course.

It was actually pediatric, so it was just external assessment, but was completely embarrassed because not many people know this about me. I've had major surgeries on my right leg, so very weak hip muscles, pelvic floor muscles, all of it, all on my right side. And I had dealt with urginary incontinence for most of my twenties around the time I was studying pelvic health physical therapy.

And I didn't have the experience that Kelsey had, but it was like in front of the whole class where the instructor at that time. And I felt so ashamed, but she said, wow, you need to really work on that. Not knowing my history, even though, I mean, my scars were like out there for everyone to see, even at that time, she's just paying attention to my pelvic floor muscle contraction, but not everything, and not my story right around it.

And I just realized, I'm just like, is even our internal or external pelvic floor muscle assessment in its isolated state, a gold standard measurement or assessment of that person and their function and all the things that we think it is supposed to mean? And it just made me question it. And I was just so grateful to Kelsey in that moment for sharing that and being vulnerable, because I think about that now. And I think, I don't know that we actually know the gold standard for every setting if we try to define it without that person's story.

When we try to define what practice should look like without a person's unique values and circumstances, we're missing everything. Not some things, we're missing everything.

Lindsey: Yeah. I'm just, I'm gonna have to re-listen to that multiple times, Rebeca, because that really, I feel like it brought together our entire discussion regarding, again, our call of why we're all doing exactly what it is we're doing. I know you're not going to stop having these conversations anytime soon, which I just love. And I'm curious if, what do you see next in terms of the questions you want to ask or the discussions that we should be exploring just to continue to deepen these conversations?

Rebeca: I think to answer that, Lindsey, I have to kind of really reflect a lot on even why this started in the first place.

At the time I was volunteering, and you might have known a little bit of the story, but I actually never really spoke publicly about it. I think it's important to revisit the past sometimes to kind of like really answer, well, what's next? What's the future? What are more conversations going to look like like this? But I was a volunteer for the APTA, Academy of Women's Pregnancy and Postpartum Special Interest Group. And in early 2022, I was doing like all these webinars and really just getting involved in bringing up a lot of conversations and panel discussions that I'm doing now on my platform, Pelvic Health Network, but I was doing it for them.

And I remember there was this one discussion that just blew me away. I was so excited. It was the first time that we actually had an OT representative on a physical therapy primary platform really say pelvic health therapy for the first time, right? Because it was always defined for me and my practice as pelvic health physical therapy and it being very specific and kind of targeted for our discipline.

And I think back now, I'm like, well, we never did that for lymphedema. We never said lymphedema physical therapy or hand therapy, physical therapy, or stroke physical therapy. It was stroke rehab, lymphedema therapy, all these things that really just kind of melded the two disciplines and included our different scopes or our different lenses.

But with physical therapy and the pelvic health world, it was very much kind of a dichotomy, it felt like. And I was so excited about this panel. And around that time, the board decided to pull it and cancel, like they did not air it.

And there were many reasons, but that was one of the ones that was cited was the term pelvic health therapy, where we were trying to really describe what we were doing with this population that included maternal health, that included women's health, that included pelvic health. But we were trying to bring both disciplines under this umbrella, and that was a big no-no. And I realized that was the year that Pelvic Health Network was born.

By the end of that year, I led several panel discussions. I had 30 people register, I had 50 people register, I had 100 people register, and it just started to get bigger and bigger and bigger. And people actually wanted more conversations that I was able to have now on my own platform, no longer a volunteer, but just this now founder of Pelvic Health Network, where I could have conversations with OTs, with PTs, with other disciplines.

And so I think the future is just going to look more like that. It's just going to be listening to the other conversations that people are having, whether it's the gold standard around virtual rehab, telehealth, whatever it is, and really understanding how they're choosing to have those conversations. Are they inviting other people to their platform? Because that's important for me to just see what the landscape is.

What are therapists who are part of these huge organizations learning? And if they're still learning in a silo, then that really truly is the landscape of the field that I'm working in, and that I'm trying to help and serve people. So I have to constantly be aware of the conversations people are having so that I can know how to respond and how to create more opportunities for more people to be present when we're talking about them.


Lindsey: I love that. And I'm here for every step of those continued conversations, Rebeca. Is there anything else that you wanted to share with our listeners today?


Rebeca: Just know this, that I don't think my reach would be anything that it is without Lindsey Vestal really inviting me first and foremost to the 2022 OTs and Pelvic Health Summit when it was first virtual. And I think I might have spoken for five minutes, and then I just stopped and waited for people to ask questions. I think that the expectation, you were on that call with me, was that I was supposed to speak for 30 minutes. And I thought later on, I just gave my five-minute spiel and then just proceeded to just wait for people to ask questions. And thankfully, there were enough questions, but I understood the assignment the next year.

And Jenna and I presented again in 2023, and then we were able to join you all in 2024. And I think that we now in our organization have more OT practitioners throughout all of Enhanced Recovery After Delivery who are members of Pelvic Health Network and trying to build this community of professionals from acute care, home health, just early intervention services for the pelvic health and maternal population. That is a direct result of the work that you did.

I can prove that. I want listeners to know this, is that from one of the OTs and Pelvic Health Summit, I believe it was 2023, we had an invitation from Sarah Lyon to talk about our paper that we presented at your summit. From that conversation, MedBridge reached out to us.

And the work that we're doing now with MedBridge blows anything away that I've done up to this point. It's on such a huge platform that's getting the word out about early OT and PT, and they've made their pathway inclusive of both providers. And MedBridge, as people know, is one of the largest continuing education platforms in our fields, and they are leading with inclusivity.

That would not have happened. And I can trace all the conversations and all the connections, and it was OTs and Pelvic Health Summit. And so I just, I mean, I want to really stress this, Lindsey, for you to hear and for you to just know that I'm saying directly to you and your audience is just the importance of really being connected with people who from the get-go think collaboration and live and breathe collaboration, which you do from the get-go.

I mean, that is just the very core of who you are. And this opened up a world for me that at the time leaving the volunteer position I had with APTA, Pelvic Health, that was really shaky and uncertain, and it was vulnerable to start something on my own. But you made it so easy for me to find my community and find my people, and I just can't thank you enough.

Lindsey: Well, I am so honored that you're coming back for 2025. We're going to actually see you in another month, and I want to give a huge shout out to the vulnerability that you have described in every step of this process, because that's really what it takes. You know, a lot of times we have to be in part of these groups where we find our place, feel our humanity, and then recognize when it's time to step outside of them.

And I certainly have been in that place many, many times, and I do feel like we are so much better together and rolling up our sleeves and feeling sort of like really, really leaning into what it means to see the other person in their entirety. And I think that I'm so grateful for you leading the way on that, and I'm honored that I could have been in some small part of that. And I just know that the work that we're both going to continue to do will just continue to lift every future client who needs us up and every future practitioner who's going to continue to carry on this work in ways you and I can't even begin to imagine.

So right back at you. I thank the world of you and all the work that you're doing, Rebeca, and thank you for taking the time to share a lot with so much of your journey with us today that we're going to continue to think on and build on in our own way.

Rebeca: Thank you so much for having me, Lindsey. Thank you.