How to help clients with an eating disorder (with Harriet Iles)

[00:00:00] Bronwyn: Hey, mental workers, you're listening to the Mental Work Podcast, your companion to early career psychology sponsored by the Australian Association of Psychologists. I'm your host, Dr. Bronwyn Milkins. And today we are talking about working with clients who have an eating disorder. It's really important to know some of the complexities of working with clients with an eating disorder, because you may not know this, but it's relatively a common presentation in psychological practice.

And if not an eating disorder, then it's cousin body dissatisfaction is also a common presenting concern. Some early career psychologists may feel very frightened working with clients who present with an eating disorder and they may overlook what's happening with the client.

But today me and my guest are here to help you feel a bit more confident in this area. I've got a wonderful guest here with us today and her name is Harriet Iles and Harriet, thank you so much for joining us on the podcast.

[00:01:05] Harriet: Thank you so much for having me today.

[00:01:07] Bronwyn: My pleasure. So Harriet, could you just introduce yourself and your non psychology passion to listeners?

[00:01:12] Harriet: Of course. Um, so my name is Harriet Isles. I'm a psychologist. and when I'm not at work, I love, um, I'm in Sydney, so I love the harbour. So anything by the harbour, reading, walking, running, um, having coffee, having tea, um, Seeing all the dogs out, you know, in the, um, the parks by the bay. So anything in nature that involves exercise, um, and particularly being by the harbour, I really, really enjoy.

[00:01:43] Bronwyn: That sounds amazing. Particularly the dog watching really resonated with me.

[00:01:47] Harriet: Rushcutters Bay, which is a, a, a, quite a popular bay, um, in Sydney has this park and there's a lot of dogs that hang out in that park with their owners. Um, and I don't have a dog myself, but I go to the park just to see all the dogs. Um, and it's, it's, yes, it's a wonderful thing to see. It's very self soothing.

[00:02:09] Bronwyn: I love how you've picked out the dog hotspot. Nice work. Thank you so much for joining us, Harriet. And one of the reasons why Harriet is on the podcast today is because you've got quite a, I guess, is it all right if I say that it's a niche in eating disorders?

[00:02:24] Harriet: Yeah.

[00:02:24] Bronwyn: Maybe we could just start out by letting listeners know how you came to work with people who have an eating disorder, like what drew your interest? Was it just luck of the draw or was there something else that drew you to this area?

[00:02:37] Harriet: I studied psychology and law and whilst I was studying, I actually worked as a personal trainer. And I worked in the gym as a personal trainer. Um, and I was also a fitness instructor. So I had a lot of exposure to, uh, different people, um, at the gym. And as I sort of started to work with people at that physical level, helping them with their stamina and building strength, I was noticing a lot of symptoms of anxiety, uh, disordered eating, body dissatisfaction, and I guess that got me really interested in psychology, as a career, and that kind of drew me to, become a psychologist working with people, struggling with, body image as well as, um, regulating their eating, um, and other kind of disordered eating, um, behaviors.

So my interest in fitness and working in the world of fitness, personal training, fitness, instructing, drew me, to, to ED work, sorry, eating disorder work, that I'll probably abbreviate eating disorders.

[00:03:47] Bronwyn: Yeah. That sounds sensible.

[00:03:48] Harriet: and then when I moved to Sydney to do my honors year in, psychology, I did my thesis, in anorexia nervosa, but working with actual rats. So we were, we explored the impact of, of, um, starvation basically on, memory and other forms of cognitive functioning, um, but using a rat model. So that then kind of, yeah, drew me to, doing some work at the Inside Out Institute for Eating Disorders, which then allowed me to go into private practice in eating disorders.

big journey.

[00:04:21] Bronwyn: such an, yeah, that's such an interesting and varied pathway. when you were saying that you're a fitness instructor as well, I was wondering, did you say lots of people who were maybe using fitness as a compensatory strategy for food, or maybe had an unhealthy relationship with exercise as well?

[00:04:39] Harriet: Definitely. So, compulsive exercise as opposed to, I guess, healthy exercise, exercise being used for just for joy, joyful movement. I, I often talk about, So yes, I, I saw exercise being used as, as a way to burn, calories and also a way to, um, manage mood and anxiety. and it's, it's can be difficult to know where the line is because obviously we promote exercise as a great way to, um, you know, enhance brain health, to regulate mood . To manage and regulate anxiety. but I guess when exercise becomes compulsive, um, and used as a compensatory strategy, and used to burn more calories when say we're already in a calorie deficit, it can become quite harmful.

[00:05:33] Bronwyn: And, and I think the reason why I asked that as well was because maybe this is one of the first, unknown traps that early career psychs can fall into because as part of our assessment, we might be asking clients, how's your diet and how's your exercise? And they're like, Oh, I eat healthy. I don't drink too much alcohol. And I go to the gym every day. And maybe an early career psych could be like, that's fantastic. No further questions. But maybe for an eating disorder clinician, you might. Inquire further.

[00:06:02] Harriet: definitely. So, I mean, I work in a private practice that is very, um, eating disorder focused. So a lot of the clients, well, my new clients come to me and I already know that there's likely to be, symptoms of disordered eating, a tricky relationship with food, a tricky relationship with body. so I guess I do definitely have to dig quite deep, um, and get an overview of, you know, what they're eating, how much they're eating, the presence of, dietary rules, their attitudes and thoughts around food, uh, body, exercise, whether there's, um, you know, purging behaviors also in the picture, like self-induced vomiting, compulsive exercise, further dietary restraint.

so yeah, we have to really dig deep as to exactly what a, the, the client's, um, diet looks like. across say a week, look at their, um, cognitions related to body food and exercise, as well as, um, just their emotional regulation. yeah, they're just some of the, the things that we touch on, in our kind of comprehensive initial assessments.

[00:07:20] Bronwyn: It already sounds quite complex. So congratulations on getting your registration last year, firstly, but like for an early career psychologist, I wonder whether maybe when you had some of your first clients, whether you noticed any feelings of anxiety come up around this complexity that you're presented with.

[00:07:40] Harriet: Definitely. When I first entered into the world of eating disorders, um, I was very excited, very nervous. Nerves and excitement are really, I guess, the same emotion.

[00:07:52] Bronwyn: Yeah, totally.

[00:07:53] Harriet: how I perceive it. Um, so yes, there were, there was definitely, just a sense of, I guess, nerves and anxiety because I, This meant a lot to me and I really wanted to succeed in it. And I obviously have a duty of care. So, I guess for me, it was just about, having good supervisors. Um, making good friends with my colleagues, continuously learning, learning from the client as much as obviously learning from my supervisors and from textbooks and from podcasts and, and it was just going in there with, an attitude of, of, positive attitude, um, curiosity and obviously wanting to continuously grow and expand as a clinician and as a person.

[00:08:41] Bronwyn: Yeah. I was really picking up on that humility. So even though you have those qualifications, which would give you that knowledge and practical experience working with people with eating disorders, I am picking up that you were like, look, I'm ready to learn more and keep on growing in this area.

[00:08:55] Harriet: a hundred percent. And I think one of the things, I say to other psychologists, I am obviously an early career psych myself, but for those that are literally just starting, in clinical practice. You learn so much from your clients, so let them teach you, because you can, I guess, introduce, the regular eating framework, and we use a special framework called RAIDS in the eating disorder space, which stands for Regular Adequate Varied or Variety, Eating with others and Spontaneity. You can introduce that to a client, but, there's likely to be a lot of ambivalence and resistance, and the client will teach you what all the barriers are to actually being able to implement that. and so then you spend a lot of time with the client on those barriers and that obviously we need to, um, to work together to overcome in order to assist them to regulate their food intake.

[00:09:53] Bronwyn: Yeah. And you bring up a really good point about the nature of the therapeutic relationship with folks with eating disorders. I just wanted to, because I can't get this out of my head, but I just wanted to circle back to you saying that it was really good that you had supervision and training around eating disorders because I'm an ED credentialed clinician.

And I think one of the things that I didn't know before I became an ED credentialed clinician is that it's the seriousness and consequences of eating disorders. And when they go unmissed, it really leaves the eating disorder, a lot of space to develop and become more entrenched. And so, It's very important to be able to detect eating disorders, but as well, take them seriously and give them appropriate treatment.

Because for example, with anorexia, it's the, it's a mental illness with the highest mortality rate of any mental illness. And that might be because of cardiac. Uh, complications and other consequences of starvation. And then there are other consequences for the other types of eating disorders, say bulimia nervosa and binge eating disorder, even ARFID.

So yeah, there's a lot there, right?

[00:11:06] Harriet: There's a lot there. So, part of what we do initially in treatment is psychoeducation and a lot of it around the symptoms of the eating disorder, the function of the eating disorder behaviors. Uh, cause they serve a lot of different functions and the consequences, the physical and psychological consequences of the eating disorder, because a lot of clients will present with a restrictive eating disorder and they will be, they likely will be a little resistant and ambivalent to treatment because restricting food intake, can often make an individual feel very in control, rewarded... and if they're presenting with perfectionism too, then this adherence to dietary rules, it's, it's almost like they're the standards that they're, they're meeting, um, which make them feel enough. and so I guess in treatment you are working with an individual that may not initially want to recover.

[00:12:20] Bronwyn: let's talk about that because from the client's perspective, with what you just shared with us, they might. You might be consciously thinking this, but essentially as a psychologist, you're saying to the client, okay, we want to get rid of the thing that is helping you stay in control and if you are deriving a sense of self worth from let's, let's dismantle that. And I think eating disorders don't like hearing that.

[00:12:44] Harriet: No, they don't. They really don't.

[00:12:47] Bronwyn: No. So what's it like working with, like, like to externalize the eating disorder from the client. Is that something that you do?

[00:12:55] Harriet: always externalize. So that's the real foundational components in treatment is learning how to externalize that eating disorder to be able to see the eating disorder from within. As the eating disorder, um, that's separate from, the individual, um, that you're working with. And so sort of you and that individual together can, fight that,

[00:13:21] Bronwyn: And so what's it like working with clients where an eating disorder has a real hold on them and is causing them to be I guess, really not wanting to engage in the treatment or being quite ambivalent about recovery because the eating disorder is saying, Hey, this person, they're not going to help you. I'm here to help you.

[00:13:41] Harriet: yeah, I love working in this space and, and, um, I really, um, enjoy working with all my clients and I guess, being with them in that. Resistance and validating the ambivalence. You know, we talk about rolling with the resistance, validating the ambivalence, and I guess it's, it's to help clients, become more motivated to fight back against the eating disorder.

we're really talking about the costs of staying the same and the benefits of change and looking at, I guess, the function of the eating disorder behaviours. Uh, for example, like to feel more in control, to feel more worthy, and then I guess inviting the client to consider how we can broaden their engagement in all these different domains of their daily living to enhance their self worth, to enhance that sense of autonomy and meaning and purpose in their life. So I often get the client to think about their values and to start to visualize where they want to go so they think they can start to think about running towards a meaningful life as opposed to running away from an eating disorder. Even though it would kind of do both, you know?

[00:15:02] Bronwyn: No, I, I really love that approach and I love the language you've used that you're inviting the client to, have a look at it in a different way and inviting them to consider that there may be benefits to reducing the influence of the eating disorder on their life as well as their values and moving towards something. I think that's fantastic.

I feel like the stage that I try to get with folks who have an eating disorder. And this is maybe not what I say to them explicitly, but for me, I very much see an eating disorder as like a cage and it's, and it's very much like trapping, trapping them and stopping them from living, usually in line with their values and what they do want out of life. So I see it as very freeing, but of course my perspective of it might not be the same as the clients and it's about inviting them to consider their own perspective and own willingness to overcome it, right?

[00:15:50] Harriet: Yeah, totally. And I, I'll often get the client to, to consider, that yes, the eating disorder makes them feel like they're in control, but right now, who is really controlling them? and We talked earlier about the, the physical and the psychological and the social, uh, consequences, of eating disorders and that's, at that point, is a really good time to get the client to really consider, um, the impact that that eating disorder is having, physical impacts, psychological, social, um, and what it could be like if they let the eating just sort of go and learned how to regulate, socialize, enhance self worth, you know, enhance relationship to body and food.

[00:16:48] Bronwyn: Yeah. So I guess like they may say that a downside to letting go or recovering from the eating disorder is that it might be really scary. They might not know how to live their life or even who they are without the eating disorder. So that might be terrifying to them, but there are also some potentially good benefits. Like they may. Reduce or eliminate headaches, bitter coldness, they may be able to eliminate some health consequences. They may be able to feel good about themselves in a different way. Um, so there are lots of pros as well that we go through with clients.

[00:17:22] Harriet: Totally. And you just, got me thinking about something that I said to some clients and patients, cause I work in private practice and hospital settings and clients talk about the anxiety and the fear that they would experience if they fully let go of that eating disorder. But I invite them to consider the current anxiety and fear that they're having with the eating disorder.

I say to rather not Be on the journey of recovery, still be in the hospital with this anxiety and fear with the eating disorder, or would you rather experience the anxiety and fear, um, as you are moving outside of your comfort zone into what I call the growth zone. And you are basically coming home to who you are, because the way I see recovery is to recover something is to actually kind of come home to find something.

So I talk about to the client, I mean, every client defines recovery differently. but I talk about putting the pieces together and connecting like mind and body and actually coming home to yourselves, and if you don't know who you are, let's go on a journey to create that and find that, you know, those you want to do.

[00:18:36] Bronwyn: I think that's really beautiful. And I think one thing that I maybe want to point out to listeners is that I anticipate that you're not doing this in the first 10 minutes when you meet the client and you're not like, okay, look at the cons, look at the pros, who's in control here. You're not in control. You're not saying this to them the first 10 minutes, right?

[00:18:55] Harriet: no, no. And sometimes. You know, it takes a few sessions to even, well, it takes a few sessions to obviously get to know someone... and in your initial assessments, you're obviously assessing for medical risk, um, as well as, risk, uh, in the sense of suicide ideation, sorts of self harm, self harming behaviors and things like that.

Once you've sort of gone through that, it might take some time for you to even get the client talking about, food. And I guess you just have to slowly move in the direction of that, um, whilst obviously providing a really safe, validating, containing space for the client in order to build up that trust. Because if you don't have the trust, got nothing.

[00:19:49] Bronwyn: Absolutely. Um, because one of the key fears say for folks who have anorexia might be, um, of gaining weight. Like that is one of the key criteria. So when they meet health professionals, they may, or their eating disorder may be telling them, this person's going to make you gain weight and you're going to get fat.

so it sounds so important to build up that validation, trust, safety, empathy, genuine understanding of who they are as a person and how this eating disorder came into their life to be able to then proceed with being like, okay, here's some of the drawbacks of the eating disorder and here's some of the potential upsides of releasing it.

[00:20:26] Harriet: And if the client is so underweight that they are, not medically stable or, I mean, a lot of clients that are even in, in the so called healthy weight range become medically unstable. Just because you're underweight doesn't mean you're medically unstable. and just because you're in the healthy weight range, um, doesn't mean you're medically stable.

Um, yeah. So having that foundational therapeutic alliance is really important because, you know, you are going to be, working with clients, to weight restore, if they have lost, uh, weight as a result of their, uh, symptoms... you've always got though the, the hospital, um, sort of setting to ensure that the client is medically stable and some of that weight restoration may start in the hospital setting.

But when they come, obviously, to outpatient treatment, um, you are continuing to work on, on that weight restoration. And it does, it does take time. and sometimes, um, it stalls and you have to kind of validate and help the client to continue on. You've got a, a GP working with you though, in the sense that the client will always be seeing their GP in addition to seeing you.

So if they are outpatient, you know, you always, know that there is that frequent medical monitoring going on, um, which kind of just helps you, to, know that the client's medically safe whilst are on this process of weight restoration.

[00:22:02] Bronwyn: Yeah, one thing I wanted to pick up there was that it, it is really vital to assist people who require wait restoration, but one of the things is that it's, it's, you know, Really hard, if not impossible to tell someone's health status by simply looking at them. Like we might look at a person and be like, look, they look quite slender or the opposite. We might be like that person's living in a larger body. And maybe those of us who haven't been trained in weight neutrality would be like, Oh, that might correlate with like a health condition.

Could you just speak to us about the importance of being weight neutral and about getting those further assessments to see what is actually going on with a person?

[00:22:42] Harriet: Definitely. and I think it's, yeah, it's really important to kind of flag from the outset, if you are going to work in the eating disorder space, just monitor, I guess, your relationship with your body and monitor potential biases. and. I guess also just how you, engage with different societal discourses, particularly around dieting.

Um, obviously there's ones around weight stigma and things like that. And so it's just important to really just reflect, because in this space, uh, body neutrality, which is, really about body function as opposed to what a body looks like. And, I guess as well with when working with clients, yes, you can eyeball them and if someone, I guess looks underweight, make certain assumptions... um, but really we, we really do need to do comprehensive assessments. and obviously you've got your medical professionals doing their medical assessments of the client too. to determine exactly what's going on for that client. I've had clients that have presented to me with a BMI in the so called healthy range.

Um, but as a result of the restrictive food intake, they had, uh, medical complications which put them in hospital, and so I guess, you know, we can't just assume that someone's medically stable based on their weight. And it's also yeah, if you're living in a larger body, we can't assume anything about anyone's medical status without having that comprehensive evaluation.

[00:24:26] Bronwyn: Yeah. And I think this is so important because there is so many studies out there that have looked at say the health discrimination that people in larger bodies face. And so they may have All of their concerns attributed to their body size and their weight, which may be completely inaccurate for them.

Likewise, a person who is in the healthy weight range, but restricting their eating to the point where, if they are female identifying and they menstruate, um, they may lose their menstrual cycle, but because they're at a healthy weight in air quotes, they may not get the medical attention that they need.

[00:25:00] Harriet: exactly. So I guess it's just being really mindful of this and. Um, there's lots of different, frameworks, uh, like the health at every size, um, approach that are very, um, much endorsed in this space, I guess to get us as clinicians really appreciating, um, this notion of health and it does come in different shapes and sizes.

[00:25:22] Bronwyn: Yeah, and I'm so glad you brought up the reflective practice required of a person, of a clinician working with folks of eating disorders, because we've all grown up with messages received from our families, our friends, uh, society, you know, like the dieting industry is a multi billion billion dollar industry, and there's a lot of hyper sexualization of bodies and pressures to look a particular way and have a particular weight. Um, so it, it makes sense that all of us will have internalized some sort of, uh, ideas about, Body shape, weight, eating, exercise. And these may not be disordered, but they may not be helpful either, right?

[00:26:07] Harriet: 100%. And the other, the other point to make I think is about, commenting on body shape and body weight as well. just being really mindful, not to ever comment on client's weight or, shape. obviously we, we do weigh clients in session. to monitor, their weight. If they are restoring their weight, then we'd be looking for that increase.

if for example, the goals, weight maintenance, um, then we'd be, you know, looking for that trend. Um, but weighing can, can, um, form an important part of, um, the information that we gather. but I guess when we are doing that and when we are talking to the client about, you know, body weight and shape. it's really important just to be mindful, uh, not to, say to a client, Oh, you're looking really healthy today, even if that's met with really good intentions, the eating disorder can get very triggered by comments like that. so I guess just keeping those sorts of comments, to oneself, if you're noticing the client looking fuller, looking healthier, looking like, you know, they have, taken that next step towards their weight goals we can't comment on that.

[00:27:22] Bronwyn: Um, so, and the reason why we can't do that, even though we're well intentioned is because the eating disorder will run away from it and interpret it as a negative thing.

[00:27:32] Harriet: The eating disorder can become very triggered by that. So comments like, you look happier, you know, you look fuller, you're glowing, you look healthier. Um, whilst obviously we mean it with good intentions, it, it can be quite triggering for an eating disorder because, the eating disorder will probably use it, as a, actually we've gone too far, and that may actually trigger, um, different emotions, um, and a whole lot of unhelpful cognitions and behaviors, um, potentially for a client.

So, it's about teaching people if they are noticing the client happier, you know, to talk about, a, their smile, or to talk about something that they've done. Such as, um, had a, a walk with a friend or went to that social event, you know, really, really encouraging the client by just noting down things that they're doing, which make up a meaningful life as opposed to, you know, body changes and whatnot, because we want the client to see that there's so much more than their weight and their shape.

[00:28:41] Bronwyn: Yeah, that resonates a lot with me and the training that I've done in eating disorders. One of the key exercises that we were taught to do with clients who have an eating disorder is draw a pie chart of things that are important in the client's life and how much space the eating disorder is taking up. And for a client who's coming into treatment, the pie chart might be 100 percent the eating disorder. And then to draw another pie chart of how they would like to fill up their life, and it might be full of hobbies, relationships, religion, things that are really important to them and meaningful that have been pushed out by the eating disorder.

And so that, that fits in line with that. We don't want to be commenting on their weight or appearance because we really want to de emphasize the importance of those things in their life and really emphasize what working towards a valued, meaningful life, right?

[00:29:34] Harriet: Yeah, 100 percent and I do a lot work with those pie charts and we use them in the context of, you know, self building self worth and perfectionism and trying to reduce that over evaluation on achievement and grades and whatnot. So I think they're really important tool and. It's um, I guess important that everyone sees themselves as multifaceted, and that they've got this inherent self worth as well as worth that is shaped by, you know, occupational performance, relationships, friendships, hobbies, leisure, I mean, that's what makes up a meaningful life, having diversity.

[00:30:08] Bronwyn: Yeah, absolutely. thank you for telling us more about that. I'm really glad we got into the topic of personal reflection. I think it was something that I hadn't considered for this podcast episode, but it is so important. and I've noticed myself even like, because. We as clinicians, like I said, we've all been internalizing society's messages. That was something that I had to work on and make sure that I was not unduly influencing clients in a negative way. So yeah, it's been really important.

Harriet, I just wanted to do a bit of a sidestep and just talk about and speak to the importance of a multidisciplinary approach to eating disorders. So I think this is something really unique about the eating disorder field. Like I know we do it for other conditions, but I feel like the eating disorder field is quite an exemplar of multidisciplinary practice. And could you just tell us the different types of health professionals you have at your workplace?

[00:31:03] Harriet: Yeah, definitely. I work with, um, dieticians, um, at my workplace. We've also got pediatricians, and then people outside my workplace, uh, general practitioners, psychiatrists, exercise physiologists, even, you know, occupational therapists. Uh, so there's a broad range of people that, that can make part of a, a client and patient's treatment team.

The minimum, I guess, members, needed, to treat the eating disorder is the mental health professional and the general practitioner. So there needs to be medical monitoring, um, alongside the psychological interventions. but a lot of the time clients will work with a dietician. I'll definitely encourage that because the dietitian can provide the client with the appropriate meal plan that will help them with their goals, whether that's, you know, weight restoration, weight maintenance, um, and whatnot. So, in the, the psychology area, we'd be looking at supporting clients with regulating their food intake and addressing, um, any barriers to being able to do that, looking at cognitions, looking at emotional regulation and whatnot, and looking at challenging eating disorder rules and cognitions, um, using our regular eating, intervention, and then the dietitian, I guess, supports that through providing the meal plan, enforcing that, and Obviously provide different meal plans, depending on what the client needs.

So yeah, it's a, it's a shared care is, is best practice and regular communication. Um, multidisciplinary team meetings, um, are wonderful because we have an opportunity to talk about what we've been doing, um, specifically one on one with the client or patient just to make sure we're all on the same page in terms of goals.

[00:32:59] Bronwyn: Do you have any tips for early career psychs who might have never spoken to a dietician or a GP as a colleague and might be feeling a bit frightened?

[00:33:09] Harriet: I guess my main tip is, to be yourself. I know you're probably still trying to find who that is as a, even as a person and as a clinician. but it's, it's really about engagement. Um, having curiosity, you know, if you're not 100 percent sure exactly what the dietitian does, ask them, you know, say that you've just started in this field, you're really excited about it. and you want to know exactly how this dietitian is going to support your client. So having that regular communication, having that curiosity, having that humility, having that interest, and, having a belief in, in oneself, that they've got the skills and, they're also growing and expanding in this space too.

And, having, the GP, um, the dietician, for example, to work with. It also, um, is, is great because you're not alone in treating the eating disorder. You've got other people in a team to support you, which should hopefully make the process, a little less daunting, cause you've got that extra support.

And I guess it also sends a clear message to the client that symptoms, symptoms of an eating disorder, Therefore warrants a team of people, with obviously different skill sets, um, to help that client to move towards recovery.

[00:34:32] Bronwyn: Yeah, no, really good things to remember there. I think it does help clinicians to feel less alone when other people are on the team. And like you said earlier, it is best practice and it can also communicate to the client, look, we're taking it seriously because it is serious and we're all here working with you and wanting to, you know, help recover from the eating disorder.

[00:34:55] Harriet: a hundred percent.

[00:34:57] Bronwyn: Thank you for speaking to that, Harriet. I think one of the last topics that I want to cover is what treatments you use and what you've been trained in to treat eating disorders. I know this might be a big question and I'm not asking you to explain all of it, but, what are the main treatments that you use for eating disorders?

[00:35:16] Harriet: I primarily use cognitive behavioral therapy enhanced for eating disorders. Which is generally first line for most of the eating disorders. But I also do Morsley Family Therapy, which is for those clients are under 18. Uh, presenting with symptoms of an eating disorder and family based treatments really about empowering family members to help, um, the young person, uh, to recover from their eating disorder.

When I'm working individually, one on one with a client who's over . I primarily use Cognitive Behavioural Therapy Enhanced. I will just say, um, on a side note, we do have Cognitive Behavioural Therapy Enhanced for adolescents, and so I do see a couple of adolescents on my caseload, where that's been, the treatment option that they've wanted to go down. So, yeah, CBT E, that's the abbreviation for it, as well as family based therapy.

I would also note that I'm a huge advocate for dialectal behavior therapy and acceptance and commitment therapy, and will often integrate some strategies such as mindfulness, such as acceptance, such as self soothing into, sort of the CBT framework, because I think that, It's warranted.

Um, and I guess, you know, my approach is whilst working within the frameworks client centred. So if I feel like the client would benefit from some grounding and self soothing strategies to use, say before dinner, during or after dinner, then I might call upon some DBT strategies, to support them with that specific, goal and need.

[00:37:00] Bronwyn: thank you for outlining the CBT e treatment and for saying that you also use DBT in ACT as well. Um, I do the same thing and I think that's because Cognitive Behavioural Therapy Enhanced is a great evidence based therapy for eating disorders, but Cognitive Behavioural Therapy in itself doesn't say much about how to regulate emotions.

It's got the cognitive behavioral aspects, whereas DBT, it's got lots of crisis management skills, emotion regulation skills, mindfulness skills, interpersonal communication skills, which can be really fantastic. And like you said, for Acceptance and Commitment Therapy, it teaches us how to sit and make space for uncomfortable emotions, which I find for Folks with eating disorders is really crucial to helping them stay the course of some uncomfortable things that they're experiencing during treatment, like feeling full, um, and stuff like that.

[00:37:48] Harriet: A hundred percent. Um, and. I often talk about, you know, the eating disorder story, and help the client to, I guess, create that separation between them and the eating disorder. I mean, that's really what externalization is, which we talked earlier. And so introducing a bit of that diffusion, that concept of you are not your thoughts, you are not the eating disorder...

[00:38:10] Bronwyn: absolutely. Yeah. It provides some distancing from the eating disorder, um, which is so important. I guess one thing that I. Wanted to mention as well, and I can feel myself about to get on my high horse, so be prepared, but we at CBTE, because I've done the training in CBTE, it's a very structured, rigorous therapy.

And, um, What the trainer told us when I was doing my training is that a lot of clinicians don't adhere to the structure and there's some research which shows that this is one reason why clients might not get the most benefit out of treatment or they might. Be disappointed with the treatment and leave early and then not be willing to come back and get treatment for the eating disorder.

So I just wanted to say to listeners that don't go in being like, I found a CBT treatment online and I'm just going to try that. And I'm just going to do like sessions like three and four, and we don't have to do weekly sessions to start with, whatever. Go get training and I would highly recommend it. I feel so much more confident having done my training. What about you?

[00:39:10] Harriet: In terms of the CBTE training?

[00:39:12] Bronwyn: You don't have to join me on my high horse, but like, yeah, in terms of like, do you feel more confident, um, having been trained in the model?

[00:39:20] Harriet: Oh, you have to have training in this area. Um, yeah, definitely. You have to have training, to administer CBT E, and, you know, Morsley family based therapy as because it is very structured, and I, I guess the other thing to note though is don't underestimate the power of the Therapeutic Alliance.

Therapeutic Alliance, um, is such an important, factor in recovery. And so there are times where the client may come to session and you'll set the agenda. And because of where the client's at, you may need to re jig a few things and maybe add in this extra skill and take that extra skill out and put it in for next week and whatnot.

Um, so I think it's just really important to, obviously adhere to the structure as best you can, because there are some things that we need to see in treatment for an eating disorder, such as regular weighing, regular eating, you know, body image work. Obviously body image dissatisfaction is one of the maintaining factors for the ED symptoms. So there's things that we need to see.

I just would also say, don't forget to be client centred too, and I guess respond to where the client's at in that moment. And, you know, sometimes clients are just not ready. prepared to start and so you as a clinician, um, if you push them, and it's actually not them deciding that they are wanting to give this a go, they'll probably just run away.

So, you know, as long as they're getting that medical monitoring, you know, they're medically stable. Sometimes you have to spend some, some sessions with them, exploring the costs of staying the same, the benefits of change, doing that motivational interviewing values work, that understanding the 'why' behind, you know, why they want to give this treatment a shot and why they want to give recovery a shot, don't rush that bit.

That could be the key to them being able to move forward successfully as opposed to if you just kind of push them because you're like, As a bit of a perfectionist, as a therapist, you're like, I've got to get all this done in every session. If you push them, they may just run away. And there you go. got a client who may be stuck with their eating disorder because they're too scared to see a therapist.

[00:41:55] Bronwyn: Yep. And I'm vigorously nodding and I'm so glad you brought up the importance of flexibility. So yeah, there are some. Essential parts of CBT-E that should not be skipped, but I agree. It's so important to maintain that therapeutic alliance because if, if you imagine yourself, like if you're pushed to do something before you are ready to do it, you're going to feel resentful towards the other person and be like, do you even understand how hard this is? I am trying so hard and you're trying to push me like way faster than I am able to go. Do you even understand? And that's if you're lucky, if the client feels. able to share that with you. Most of the time they will just leave. So it's so important to be able to have that flexibility and be collaborative and person centered, like you said.

[00:42:42] Harriet: Definitely.

[00:42:43] Bronwyn: Harriet, is there anything that we haven't talked about today, which you really want to get across to listeners, which we should talk about?

[00:42:49] Harriet: I think, my final words would be, it's an amazing field to work in. It's, it's extremely complex and there are a lot of different factors that can contribute to the onset and the maintenance of the eating disorder. And so on the surface, it looks like, disordered eating but as you, take off kind of layer by layer, or peel, it's like an onion, really.

[00:43:16] Bronwyn: Yeah, I was going to say, I often think of eating disorders like an onion.

[00:43:21] Harriet: You're going to get to the heart of it. And I haven't really met a patient or a client that hasn't had shame at the core of the eating disorder. Shame, the belief I'm not enough. Emotional dysregulation and distress intolerance and obviously body image concerns, which I think is kind of tied to the shame and being not enough.

And I probably put perfectionism in there as well. And I think it's so tied to shame though, because shame being I'm not enough and perfectionism basically existing as a coping strategy. Perfectionism being the, the relentlessly high standards we impose on ourselves in order to be enough and to do enough.

And what often happens is people impose these high standards on themselves. And those standards look like achieving this grade at school, um, getting those people to like me and whatnot. And then when people start to realise they don't have 100 percent control over whether they adhere, successfully adhere and meet those standards, then We can turn to eating disorder behaviours in order to, I guess, somewhat meet other standards we feel like we can control in order to feel enough and be enough.

[00:44:36] Bronwyn: Yeah. And I mean, thank you for summarizing eating disorders for us. It's really good to be able to understand that. And I think it, it generates a lot of empathy. It's like the person before us is a person who may hold a lot of shame about who they are fundamentally. and you know, they haven't, I know no psychologist would believe this, but they haven't developed an eating disorder as a lifestyle choice or anything like that.

it's. It's something that is a manifestation of psychological, I guess, unrest within themselves.

[00:45:07] Harriet: Definitely. And just, I guess, to also, note you know, a lot of these behaviours have addictive properties, like bingeing and restriction and whatnot. And, Yeah, this notion of numbing pain. A lot of, a lot of these behaviors are used to numb pain. So I think where I was going with that was that they're really interesting to work with. And if you do decide to work with eating disorders, I'd really hone in and just. focus on that to reduce the cognitive load because it's already going to be, um, heavy stuff, but it's most incredibly rewarding. And the relationships, the therapeutic relationships that you form with your clients, you know, they teach you things and you teach them things too.

It's an incredibly rewarding space and I would encourage anyone if they've got any interest, to really give it a go, whether they can just do it on a placement as part of a university degree. yeah, definitely give it a go because, um, you'll learn a lot.

[00:46:04] Bronwyn: Thank you so much. And I know I'm going to get questions about this. So could you just tell us where someone might do training for CBTE or the Maudsley family based model?

[00:46:13] Harriet: Definitely. Okay, so you can do like an introduction to eating disorders, training through the National Eating Disorders Collaboration. Um, Inside Out Institute have a wonderful course called The Essentials, um, that outline all of this, all of the different therapeutic modalities, all about just general psychoeducation around eating disorders.

Body, um, matters, Australasia also host a lot of different CPD events. Um, that's where I did my training, for Morsley, family based therapy, and did some of my CBT E trainings there, so that's online for people to do as well.

[00:46:56] Bronwyn: Awesome. And I will just pop in that I did my training through Body Matters as well. And specifically through Dr. Carmel Harrison, who is a dead set legend. She is so expert in the area of eating disorders. And I did my training for binge eating disorder through Carmel as well. So I will pop all those links in the show notes and I would highly recommend as Harriet said, if anybody's interested in this area, we need more eating disorder clinicians, like it's an underserved area. There are lots of people in need who really require the expertise and we've got to give them the best treatment that they deserve.

[00:47:29] Harriet: 100%.

[00:47:31] Bronwyn: Thank you so much, Harriet, for coming on the podcast. I really appreciate it. Thank you for your time and expertise. It's been so lovely to have you on.

[00:47:38] Harriet: Thank you so much for having me. It's been wonderful to have this conversation and to raise more awareness of eating disorders, um, and the different therapeutic modalities and, and, um, how clinicians in this space can contribute.

[00:47:51] Bronwyn: Awesome.

Well, listeners, as always, thank you so much for listening and thank you to the Australian Association of Psychologists for sponsoring the podcast. Listeners, if you're loving the show and you don't want to miss an episode, be sure to press follow on your podcast, listening app. That way you get the episodes straight away as they drop.

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Okay. That's a wrap. Have a good one. I'll catch you next time.