Understanding Eating Disorders: Motivation, readiness, & support with Dr. Josie Geller

Dan is joined by Dr. Josie Geller, Associate Professor of UBC Department of Psychiatry, Division of Adult Psychiatry and Mental Health Services and the Director of Research of the Eating Disorders Program at St. Paul’s Hospital in Vancouver.

Dr. Gellar shares her personal journey with eating disorders and how it shaped her career in psychotherapy. She discusses the importance of understanding the function of eating disorders, the role of motivation and readiness in treatment, and the shift towards a more compassionate and individualized approach to recovery. Then, Dan and Dr. Geller highlight the significance of self-compassion and the need for a supportive therapeutic relationship in facilitating change.

Special Guest: Dr. Josie Geller

Centre for Advancing Health

The power of feeling seen: Perspectives of individuals with eating disorders on receiving validation

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Chapters

• 0:00 00:00 - Introduction and Guest Overview
• 2:05 Dr. Josie Geller’s Personal Journey into Eating Disorder Research
• 7:15 The Role of Therapeutic Relationships in Early Development
• 12:00 Overview of Eating Disorder Treatment Programs
• 17:40 Understanding the Function of Eating Disorders
• 22:25 Avoidance and Emotional Regulation in Eating Disorders
• 27:10 Assessing Readiness and Motivation for Change
• 36:45 Reducing Dropout Rates Through Readiness-Matched Treatment
• 40:20 Harm Reduction and Quality of Life Approach in Severe Cases
• 44:00 Transition to Self-Compassion Work

Transcript

0:00

[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to episode number 43 of Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights, pull back the curtain, and hopefully have some fun along the way. If you find the show interesting, it would be much appreciated if you shared it with someone you know who might enjoy it too. It's a great way to spread the word and keep the conversation going. Today I couldn't be more excited to welcome one of the world's authorities on eating disorders. My guest is the Director of Research in the Eating Disorders Program at St. Paul's Hospital, Associate Professor in the Department of Psychiatry at the University of British Columbia, who received multiple awards from Michael Smith Foundation for Health Research, including several research scholar awards and a health professional investigator award. She's contributed to the development of clinical practice guidelines for eating disorders in British Columbia and has served as the President of the Eating Disorders Association of Canada. In part one of our conversation, we discuss the function of eating disorders, the importance of readiness and motivation in treatment, the paradox of distress and readiness for change, quality of life and harm reduction in treatment, and much more. This episode begins with my guest talking about how she got into studying eating disorders. So without further ado, it is my pleasure to welcome my very special guest, Dr. Josie Geller.[Music] Yeah, so you know, I thought a lot about how to add to this question whether I would give you the more canned response or the more honest response, and I think I'm old enough that the more honest response is the more interesting one. You know, when I was a kid at Teenager, I had anything to disorder, and I saw a psychologist to get some help, and my relationship with that person changed my life, and I remember just thinking afterwards, I want to do what this person does, and what just seems like such an incredibly powerful time to meet with somebody, you know, when you're young, in my case, I was a teenager, and it was very inspiring for me to be able to do what she had done for me. So that was really how I first got interested. So you might have asked like, what was it in particular that was like special, I guess, about that relationship? Yeah, you know, I think for so many of us when we develop an issue that's troubling us in some way, whether it's eating disorder or avoiding things in some way, we don't always know exactly why is this happening. We just know that it's happening in my life, and it's troubling me, and so there was something about the qualities of that relationship where it was possible for me to in a safe environment, explore and understand myself, come to a different type of understanding of myself and I had ever had before. That just was a gateway to so much more curiosity about myself, and ultimately being able to grow and develop in ways that I had been inhibited before that. Wow, okay. It was a really big thing for me to kind of understand that the way of thinking that I had had up until that time, which was very formed by the relationships and situations that I had had that they were alternative views of what was going on. And so it was more that it opened my own way of thinking to see myself and my experiences as they were there were more ways of thinking about myself than the narrow view that I had, which was much more based on the kinds of achievements that I had and accomplishments that I had and not so much on really knowing myself and knowing what maybe feel more fulfilled and happy and comfortable with my skin. So a lot of what we talk about on here is very like psychotherapy process stuff. Yeah. So what I'm sort of want to ask is do you think that it was within your relationship with her? That that sort of came about, do you think it was in what she taught you more explicitly? Does it, does my question make sense? Yeah, I, well, I remember her asking questions that up until then I had thought were given, you know, that the path to happiness was to, you know, to be a good student, to do the things that adults expected of me to please other people. And the idea that there was space to think about, you know, what are actually the things that matter to me? And is there room for me to consider my own interests and needs in this? Was, you know, my sound kind of strange, but that was quite new. My focus had much, had been much more externally focused. And she really opened my eyes to being more tuned in to some of the things that I wish for for myself. And that I might not even have known, but also just being aware how little I, how little attention I paid to what my own roots were. Right. Huh. So this is probably going to roll into your work very, somewhat seamlessly before we dive too deep into the specifics of your work for the people who are listening. And honestly, for myself, who's more naive or novice in terms of thinking about eating disorder treatment, I was wondering if you could sort of give us a 30,000 over 30,000 foot overview of like what and maybe using your own eating disorder program that you work in, like, what that even looks like. Like the recovery process or developing anything disorder. Oh, the treatment process. Yeah, yeah. So recovery or treatment or what? Yeah, yeah. So I mean, I think in any disorder like so many other psychiatric issues, I mean, disorder very often develops because it's the best solution to a problem. You know, that it used to be that people would come in for eating disorder treatment and we would think that the solution was to give them a meal plan and to provide them with some behavioral changes that they should be doing. And without having a really good understanding of how to feed in disorder, somehow come to be a solution to a problem in this person's life. What is the function of the eating disorder? Whatever we did, whether it was making recommendations for eating or changing thought patterns or whatever, we're unlikely to be that helpful. So just like I guess in my own situation where I understood that having a focus that was very on what others wished for me and what the requirements or expectations were and learning that focusing on what was happening for me and what my wishes were was really important. There's something about the eating disorder that is a way of avoiding dealing with something painful and difficult and that recovery looks at trying to figure out what are those areas that might be difficult to approach and to find tools to deal with them differently. So help me understand like when you say that it's a way of avoiding other things that's one of what I don't understand how that works. How does how does an eating disorder facilitate that? Yeah, yeah. So, you know, I think so often people come to treatment and they just know that they're doing this thing with their eating, whether it's not eating enough or having issues with engine and purging and very often they know that it's causing problems in some way and they might feel like there's something wrong with them because they're doing this thing that's clearly harmful. And you know, very often society focuses on well it's just because it's out of vanity or because they will look a certain way or they care so much about their appearance. But actually the symptoms of an eating disorder it turns out fulfilled a valued function in the person's life. Whether it's what are the my graduate students many years ago developed a measure where we looked at you know what are we all know what the cons of an eating disorder are but she was looking at what are the pros that means you know if we were to do sort of like a decisional balance what what are the features or what are the functions that an eating disorder is serving and one of the most important pros of the eating disorder that well it turns out to be both a pro and a con we call functional avoidance and that is that somehow the eating disorder helps me to avoid something painful or difficult in my life. It could be just when I feel overwhelmed by emotions it's it's a way that I can not have to feel those things so if I'm binging for that period of time I can numb out or not have to experience those things or have some distraction if I'm restricting there's actually a benefit of restricting where I stop to feel anything intensely. In fact it sort of numbs me out to things in general I can really focus on maybe the number on the scale or what I've been eating and it keeps me away from something that might be more painful you know whether it's some immediate feelings or maybe it's something like a bigger issue like taking on adult responsibilities or having to deal with trauma or difficulty in my life that the eating disorder is something that may look at least initially socially sanctioned because it's helping me to look a certain way but it's also helping me to not have to deal with something that's really painful. So then is a large part of effective helping figuring out what that is what that what that problem is. Exactly and when we go into treatment without having a good understanding of what are the functions that the eating disorder is serving it's really hard to move forward and that's when we typically you know particularly in the olden days before we paid attention to issues of readiness and motivation you know we'd be standing over these meal plans and you know behavioral contingencies but without having the understanding of what was what brought the eating disorder into my life in the first place it's unlikely that any of those changes are going to be okay. Right so then it's okay so if I'm if if I'm a patient who comes into your program like what what does that look like like what does my experience look like? Yeah well I remember when we first started to do this work and I was like fresh out of graduate school and I would see some patients you know at the assessment stage and what became clear to me is that although for many of them they had a mother or a father or a partner or somebody who was really keen for them to go on to recovery that they themselves often were not in that place that they often had a lot of end of ones that making changes and you know our program like so many other programs around the world had very high rates of treatment refusal and dropout relapse and we worked out that until we had figured out that the individual was making changes for themselves that it was unlikely that they were going to have a really positive or consistent positive outcome. So I got interested in writing this in motivation because that was something that we had seen in the substance use literature you know where they hit describe different stages of change that people go through and the importance of having a collaborative sort of relationship with individuals and wondered if those principles applied to eating disorders and so we started out way back when we developed this very simple interview called the latest motivation interview where he would you know the patients would come in and they would meet with a medical person and they would meet with somebody who would do a psychosocial assessment so basically how they're life circumstances and then they would also get a research assessment and the research assessment we would let them know that the purpose of this interview is for us to get the best possible understanding of what you think is going on with your eating and what if anything how you feel about what's going on and what if anything you want to make changes to it and we want you to know that the contents of this interview we're not going to share with anybody so it's confidential and we're we have no preference or preconceived ideas about you being ready or wanting to change and back we think that we can be of greatest use to you by having the best possible understanding between you two of us of how you feel about change so that we can help you make the best decision for yourself and then we went through all the different parts of the eating disorder you know dietary restriction, vinging, purging and so on but in each case the purpose was to find out what was happening for them, how much that behavior was occurring but more importantly was there any part of them that didn't want to change it and was there any part of them that was you know thinking about it but not necessarily making any changes and of course any part that's actively working on change but the the part that was most important was the part of them that didn't want to make changes and so they would actually divide themselves into a hundred percent where they would say how much of them is in each of those categories and then we threw in this other category that turned out to be super important where we would ask them you know if you are making changes how much of that is for you versus for somebody else and we called that the internality question so in many cases they would say sure I'm actively working on change but I'm doing it because you know and in this program or because my parents are making me or asking me to but if it were up to me I wouldn't be making these changes and what we were very surprised to see is that up until then in our program when we first started to do this work we had a 40 percent dropout rate from our residential treatment program and that was pretty common in lots of programs that had you know framework and behavioral contingencies where there's an expectation for change and we didn't have any way of knowing which were the patients who were going to benefit from treatment and which ones were going to drop out and so we basically did what everybody did we took the people who had the most severe symptoms and put them into treatment and hoped for the best and what we found was when we started to assess readiness was it was the first time even though we had looked at a number of variables the intensity of their eating disorder of their psychiatric comorbidities we had never been able to determine which patients were more likely to benefit from treatment but when we started to do this interview we're in this confidential place we were having these open honest conversations about how do you feel about making changes and that's important for you what they were telling us their scores on the RMI were predicting every clinical outcome variable that we assessed so they would predict who enrolled in treatment how much people symptoms changed post-treatment whether they dropped out from treatment and what really dumbfounded us was their baseline readiness score so the extent to which they said they were interested for themselves to make changes to their eating disorder predicted whether they maintained their changes or relapsed at six month fall so six months after they completed treatment it was associated with who maintained the changes and who went back to having a eating disorder so that was really kind of mind-blowing for us because it was the first time that we were able to determine who was going to most benefit from treatment and it really changed the way we and I think programs all around the world did business we started to understand that if we had a mismatch between patient readiness and the treatment that we were offering that we would have much poor outcomes than when the treatment was matched to their rights so you've done a lot of work in the area of motivation for change could you just before we I've bought specific file-ups but I think there could be value in like what does that model or framework look like like in terms of their what motivation how motivation changes over time or yeah and like you know the different stages of motivation for change and how like the conceptual framework that you you know use for thinking about how how motivated people are or where they are sort of on that continuum well one thing that we learned is that motivation is not a static thing in fact it's very common for people to move in and out of feelings of motivation so it's not a static state that it's important to continue having conversations about motivation and we started to assess motivation at baseline and we started to see the need for a menu of treatment options that's tailored to readiness so if we have action oriented symptom reduction treatment program that somebody who's saying I'm here to please my mother or my dad and it's really not something that I want to do right now that they would be unlikely to benefit or even stay in that kind of treatment program so once we understood the powerful need for assessing readiness we developed preparatory treatments for our programs at St. Paul's so rather than put people into an intensive treatment program irrespective of their readiness we developed what we call the readiness program where they would go in and they would have an opportunity to explore what is the function of their eating disorder we learned what are some of the factors that are associated with improvements in readiness and we developed brief treatments that specifically target those variables so for instance we learned when we looked at people on our weight list whose readiness improved that those improvements were associated with a greater understanding of the function of their eating disorder so that's really important and we think that a big part of that is I think very often people who have eating disorders are very part of themselves and critical and they might think that there's something wrong with themselves for having this eating disorder but having an understanding of the function is starting to not feel like they're to blame for everything that maybe it came into their life for a good reason and it's it's serving a role that's important in their life and so getting and understanding of the function actually is associated with feeling less distress and it turns out that distress is also associated with low reinness that as people feel less distress or less depressed and anxious they actually feel more ready for change so you can imagine how if somebody comes for treatment and they're already feeling like there's something wrong with themselves because they have this eating disorder and now they're put in a situation where someone's telling them that they have to eat and do the big behavioral changes that that actually increases their distress and we've found that when their distress is higher their readiness and motivation goes down so it just actually creates a problem that gets worse and so without meaning to we and lots of people can't stop around the world we're inadvertently decreasing readiness and creating some of my atrogenic effects from treatment where people who are already feeling not good about themselves we're feeling more distressed by the program not being matched to what their needs are and actually increasing their distress. Well that's a little that's a little counter and not what you just said but the like you know if my two thirts if my two thirts a little bit I'm not going to the dentist but if my two thirts a lot and it hurts a lot for several days that I'm going to go right so that sort of increases my motivation where what you're saying is there's at least somewhat of a paradoxical effect here that if their distress is extreme that that's going to be less related to their readiness for change. Yeah because the eating disorder was a way of managing distress so the more distressed they are the more that the eating disorder helps them to cope in some way so by binging and purging or by restricting those are actually ways that I help to soothe myself they're not perfect but they're the best that I've got so far so if I go into a program where they increase my distress I actually need my eating disorder more not less in order to soothe myself and make myself feel better. Is there a lot of parallels here with substance use disorders? Very much so I think the function that substance use serves is very similar to the function that an eating disorder serves you know so we basically learned that people whose readiness improved over time on our wait list were people whose distress actually went down their understanding of the function of their eating disorder increased so they had more insight about how the eating disorder helped them to avoid painful experiences so they weren't being so hard on themselves they were more understanding of what their situation was and why the eating disorder came into their life and we also found that people's what they valued what they thought was important to their sense of self change a little bit where when they first started they were typically valuing shape and weight as something that would make them feel good about themselves and people whose readiness improved were valuing other things like connections and relationships and some kind of bigger purpose in life like a higher value or a spirituality or something else was coming to take some of the space that the previous focus on shape and weight was taking so we saw these configurations and you know not feeling so freaked out having a better understanding of themselves and having more importance placed on connection and higher values that was associated with improvements in readiness and so what we started to do was we started to just help people to work on those things rather than the eating disorder when they had very low levels of readiness and what we found as soon as we started to incorporate a readiness model into our into our treatment team so whereas before we would just take people who were most sick and stick them in program and hope for the best now we were taking people whose readiness was matched to the nature of the program so when they had an opportunity to understand and they're eating disorder better and to learn more about themselves that they could then decide for themselves when it was time to come into treatment and they had some space in the readiness program to make that decision and then our dropout rate within a five-year period went down to 20% to 40% and the last time I the last two were very lucky in our program we do regular continuous quality improvements we're always looking at our outcomes every couple of years and the last two runs of our data we found that it was down to 12% and 29% so when we use this kind of approach that people are going into treatment when they know exactly what they're signing up for and they've made the decision that this is the best thing for me that they are no longer kind of feeling and need to run as soon as things get difficult to take on their their because it's really what they want to do and they have a different kind of commitment to be there. I want to just just something you said I just want to sort of bring a little more attention to it because it's really powerful which is that I want to say simply and not saying it's simple but simply knowing what the function of your you know eating disordered behavior is reduces distress increases motivation. I mean I think that that like and I would imagine that the way that that looks in practice is a very you know it's not just you know an assessment oh this is what it is it's a tailored sort of slow thoughtful working with the person to understand their life their experience all that sort of stuff to get to really help them discover it with you you know collaboratively but I just think that that's just so worth highlighting because that is just you know again this it's not you know it's not doing something really dramatic with their diet and reframing their thinking about food but just understanding how this thing functions for me personally in my life that you saw that that really turned the knobs on all of these important variables I just think it's so powerful. Exactly yeah and it really speaks to the role that shame in self-criticism often has in maintaining a eating disorder so you know until I have an understanding of the function and I've had space to think about myself in a more open curious less blaming way I really do think that it's because there's something wrong with me whereas when I have an opportunity to say oh yeah well maybe I never really did get an opportunity to figure out how to you know cope with difficult emotions or you know I've had some trauma and it's really scary to move in this world when I'm worried about getting retraumatized or having painful experiences coming up again that the eating disorder is providing some way of making me feel safe and until I have an understanding of that and then an alternate way to make myself feel safe why would I give it up it's basically it's the thing that is helping me feel like I can survive so and very often people talk about it in dramatic ways like that that it would be you know really threatening to their sense of self to give up the eating disorder until they figured out how to have their most basic internet in a way that doesn't require eating disorder so is it worth talking about I was reading about this tool you develop you were a part of developing that stated yeah yeah that was really fun yeah so before I guess before we our group and other groups we certainly aren't the only group that's been understanding the role of it right in this motivation place in recovery from a needing disorder you know the for instance the American Psychiatric Association guidelines would describe you know what how do you know what sort of treatment you should give to what individuals and the way that the guidelines I think most of the guidelines had been set up where people who have more severe eating disorders you know have more medical issues and there was just an assumption that they would have the lowest level of motivation and people who have less severe eating disorders have obviously fewer medical complications and would have greater readiness and so there would be kind of like a you know most severe to least severe and the most severe would be the most intensive treatments and the least severe would be the least intensive treatments but you know we found and I think everyone was aware of patients that don't actually fit that configuration there are some people who's eating disorder is not that severe but who have very low readiness to make changes and there are people who's eating disorder is very severe but actually who have very high readiness to make changes and so the guidelines that existed didn't really have a home for all of the combinations of symptom profiles and readiness profiles that people came in and so we developed this tool this is back in 2013 I was a conduit to create the DC Competit Practice Guidelines for Eating Disorders and we thought of a new model where we just took the three variables that seem to be of interest an individual's medical stability their life interference so how much their life was being impacted and you know whether they were good with school or work or that kind of thing and then their level of readiness and motivation which had never been considered before and we made a tool that you could look at all three of those variables independently and there would be a home for every combination of high versus low and each of those things and you know I can take you through it that if you we have a little flow chart diagram that if you know you start out the first thing you would ask about is their medical stability and that's just a no-brainer if somebody is medically unstable we don't need to ask any more questions they need to go to hospital to stabilize things that could be a threat to their life or to their home so medical stability is stand alone you don't need to know about anything else but then the next question we would ask is about their life interference and if their life interference is low then it would be appropriate for them to be in an outpatient treatment situation and then the last question we would ask is their reinist and motivation so for people who are not that sick and who are highly motivated those are the perfect candidates for all of the three letter acronyms that we have out there CBT so cognitive behavior therapy DBT I like to go behavior therapy there's lots of them family-based therapy for children and families but those are the patients that will most benefit because they are saying you know that they're not that sick and they're really interested in making changes and so those treatments are really beneficial for them is great data and evidence to support them so sort of like because they're but like because they're so motivated that you're almost like they're gonna whatever you give them and these are what I shouldn't say whatever is all you know well-supported treatments and all that sort of stuff that they're gonna run with it and they're gonna yeah and I don't mean to apply that they actually have you know no ambivalence about change because everybody it's it's just relative that these are individuals who are willing to engage in a treatment that is focused on full recovery and so and then there might be another arm of individuals who are you know not suit not that sick but who have very low levels of motivation and those individuals might benefit from some work on psychoeducation or motivation enhancement to basically get them over to the other arm where they could benefit from all the CBT's and DBT's and so on so that arm is fairly simple you know they're not medically at risk they have life interference that isn't completely paralyzing and they either have motivation or not and we aim to get them all into the evidence based treatments but in the state of there's the other arm of people who actually have a large amount of life interference and who have not benefited from the outpatient options such as CBT or DBT and DBT with those kinds of things and so in those individuals we would also assess their rein and those who have a higher level of motivation would be those who would benefit from the treatments at St. Paul's where we have an active inpatient program and a residential treatment program that you know we've got amazingly skilled staff and a program that helps them to come to a best possible understanding of the function of their re-disorder provides lots of structure and support they learn lots of skills to help them manage distress and cope with difficulties in new ways and they can work through both the inpatient and residential treatment programs and really when you come out of the residential treatment program people are looking pretty recovered because the behavioral contingencies of the program are that if you're underweight a gaining weight if you have vinging and puraging that you found alternate ways to to deal with emotions and is really a huge amount of support in that program not only is this other group who are high life interference but have very low level of motivation and very often these are folks who have gone through maybe lots of treatments in the past and just not benefited from them or maybe short term benefited but have ended up still having quite a severe illness and we've learned that they do not benefit from lengthy hospital admissions that actually that makes it even harder for them to feel a sense of quality of life with progress and we've been moving to using and this is maybe one of the controversies in the field to be using more of a quality of life psychosocial rehabilitation harm reduction model with those individuals where we engage with them we talk with them about what's important for them we're not forcing symptom change on them because they've already shown us that that hasn't been helpful for them but instead try to help them have a greater sense of purpose in life because they're doing things that matter to them and that are important to them and very often they do require some hospital admissions but instead of them being urgent and you know in the old days we used to certify people against their will they would come into hospital very often they weren't interested in coming we moved to having the help of an ethical decision framework where we would talk with them beforehand and very often their loved ones people that they thought were important to care and work out together under what conditions coming into hospital would happen and we would have a promise to keep the admissions as brief as possible and focused exclusively on medical stabilization that we wouldn't bring them into hospital and then say okay let's see a weekend you know fully re-nourish them and get them to full recovery because they often experienced that as actually quite traumatizing when it happened not in in a way that they were ready to do so and what we found go ahead don't know you got well we found interestingly when we use that approach is that for many individuals when they stopped fighting the system and talking about you know very often they would be very unhappy when they got forced to come into hospital when they weren't ready that in this way of helping them with things that actually matter to them like they're often they would talk about you know when they had some space and they felt like it was safe to to talk about what they really wanted and that they weren't being pressured to do something that they didn't want they might say yeah you know I actually I feel quite lonely I know I'd like to have more connections in my life or I'd like to develop a hobby or a craft or something that would put me in contact with people or something that's meaningful to me and very often as they would get engaged in that and they would be supported to do that and they would figure out okay I'm not going to eat you know a full meal plan but I'm getting eaten up so that I can enjoy that activity or I'm going to make sure that I have space in my life so that I can do that very often they would have an appetite to do more of that and it wasn't uncommon for those individuals to ultimately over a longer period of time end up in this in the full on recovery focus so what's the controversy well part of it is political I remember Dan when I first this was you know early on in my career when I had just started to learn about motivational enhancement and I was working on a program that at St. Paul's we had to develop was four people who fit that criteria they had we now call it had a long standing eating disorder we used to call it severe and enduring and some some people who piloted that that might feel stigmatizing or kind of not hopeful about their outcome when actually very often people there's lots of reasons for hope that we see people recovering at every different stage of the illness anyway I was working in this program that was supposed to be focusing on quality of life and harm reduction and I remember having a conversation with a patient who you know was she was quite amazing how much she would exercise and how little she would eat and she was somebody who was a revolving door hospital admission she was regularly coming into hospital when she was being certified she was very angry and she would be saying you know you guys can't do the kinds of things that I can do you know in terms of activity she was a bike rider runner and she did all kinds of really amazing things you know why are you making me kind of possible and I remember my first interview with her I asked her about her activity level and rather than you know kind of try and tell her how dangerous it was or how you know how she was at risk of harming herself I just asked her what she liked about the extreme long distance biking and running things that she was doing and when she sensed that I wasn't going to kind of school her for it she told me how great it was and how she loved the feeling of wind in her hair when she was riding her bike in the sense of power and agency that she could do things that nobody else could do and I remember thinking what would people say if they heard me doing this interview because I just joined with her and reflected how amazing it would be to feel so powerful and it's true she is really powerful she can do things that we can't do and how it did sound amazing having the wind in her hair and how you know liberating that felt for her and when I share with her she opened up more told me more about the things that she enjoyed and then I asked her you know how did you feel the the next day after you did you know I remember she used to ride her bike all the way to Whistler and back and on hardly any food at all and then she would she said and it was kind of the first time she admitted to it you know I couldn't go to bed the next day and you know because I felt so terrible and was so so tired and I remember when I was asking her those questions I remember worrying that I would get in trouble for like maybe condoning or looking like I was condoning the behavior behavior. But actually what I was doing was I was just trying to learn and share with her experience of what mattered to her. I was reflecting her emotional experience and truly trying to get to know what was important for her. And when she then talked about how hard it was for her to get out of bed the next morning, I asked her if she would be interested in working together on ways that she could continue to do the things that she enjoyed but wouldn't have some of those negative consequences of being able to get into bed or out of bed or being forced to come into hospital. And that was something she was really interested in. So controversial in that I was joining with her in a way that up until then we hadn't really been doing it. I felt that the expectation had been prior to that that we had to say, "Oh, that's a bad thing, you shouldn't be doing that." And I just allowed myself to go on the journey with her. And interestingly with her we did this amazing plan. We called it the closet plan where she decided that she would take her commitment to want to continue to do these activities but not have to come into hospital. She would take all of her toys, her bike, her running shoes, her roller blades, all of these, her skis and put them into a closet. And she could go in the closet and use them at any time but she needed to eat her way into the closet. And so we had a dietician who helped us and said, "Oh, if you want to do that, you're going to have to eat this." And she started to do that and amazingly that was the last time she came into hospital. So up until then she had been like a monthly repeat customer. And she was somebody who at least there was the time that I saw her. She didn't get to the point of full weight restoration but she got to the point of going back to work, having friends, and having a health that allowed her to do things that were really important to her and that didn't require regular medical admissions. So that's the part that's a little bit controversial about this, about using motivation as a determining factor for the kind of care that we offer. There are some people who might say we're denying patients full recovery by not working within one of the three-letter acronym frameworks. But our thinking is that, first of all, for those individuals we've tried those models and they haven't benefited from them. And in really listening and getting a clear idea about what matters to them, very often they move to something either close to recovery or to something that is a better quality of life that requires less reliance on the system. So is the pushback that it's always hard for me to play devil's advocate to what you're suggesting because it seems to me to make a lot of... Is it because the approach that you're suggesting is less top down, like it's less this is where you need to go? Well, because some people might say that in working with a harm reduction model, we are not going for full recovery. And so we are denying our patients the opportunity of full recovery. And so, you know, others would say that they haven't benefited from that kind of approach. And, you know, the debate is, is it okay to not... You know, some people might see that as giving up on full recovery. And, you know, I would argue that it's not. It's just saying at this moment in time the patient isn't ready to fully engage in that and the door is always open for them to move into one of the more recovery focused options. Right. It's not like you're for closing. It's not like you're saying they can't go further. No, no. You know, I think at the end of the day, then the ingredients of treatment are pretty similar across all different models. You know, I think sometimes we get very wedded to, you know, I want it to be my model that wins in the end. But, you know, I guess I'm a much more interpretive person or a therapist in the way that I work. And, you know, we need to have some kind of connection. We need to have, you know, a kind of engagement with the patient. We need to have an understanding of the function of the illness. We need to, you know, have some skills to have alternate themes of coping with things. And we need to have some kind of vision of what's a what's a better life than myself and what I have right now. And I think we do that in all different ways and at this model is really just focusing more on the engagement piece and on the quality of life piece. And in terms of the behavioral change required to go on to full recovery, that's done in a much more gradual way. It seems like this would be a reasonable place to sort of transition into your more recent work on self-compassion. That's a wrap on the first part of our conversation. As I noted at the top, it'd be much appreciated if you spread the word to anyone else who you think might enjoy the show. Until next time.(soft music)[MUSIC]