Self-Compassion in Eating Disorder Recovery with Dr. Josie Geller

Part 2 of the conversation with 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.

Dan and Dr. Geller explore the significance of self-compassion in the context of eating disorders, highlighting the barriers individuals face in practicing self-compassion and the role of validation in overcoming these barriers. Then, they discuss the importance of collaborative care over directive care in treatment settings and critiques the current DSM-5 criteria for eating disorders, advocating for a more inclusive approach that considers life impairment rather than strict diagnostic criteria.

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 Introduction
• 1:19 Integrating Self-Compassion into Eating Disorder Treatment
• 4:35 The Role of Self-Compassion in Recovery Outcomes
• 6:52 Barriers to Self-Compassion: Meeting Standards & Emotional Vulnerability
• 9:25 Power of Validation in Treatment
• 13:00 Four Levels of Validation and Their Impact
• 16:56 Balancing Structured Eating with Readiness
• 20:00 Residential Treatment and Readiness for Change
• 22:45 Collaborative vs Directive Care in Practice
• 27:24 Therapist Characteristics and Collaborative Stance
• 30:03 Family Members: From Fix-It Mentality to Unrelenting Connection
• 34:36 Reflections on DSM-5 and Eating Disorder Diagnoses
• 36:32 Resources and Final Thoughts

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 44 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 useful, it'd be much appreciated if you shared it with someone else who might enjoy it too. Today, I couldn't be more excited to welcome back one of the world's authorities on the treatment of eating disorders. My guest is an associate professor in the Department of Psychiatry at the University of British Columbia, director of research in the Eating Disorders program at St. Paul's Hospital, has received multiple awards from the Michael Smith Foundation for Health Research, including several research scholar awards and health professional investigator award, 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 this part of our conversation, we discuss several aspects of eating disorders treatment, including integrating self-compassion into recovery, barriers to self-compassion, collaborative care versus directive care, evolving perspectives on eating disorders, and much more. This episode starts with my guest talking about integrating self-compassion into her practice and research. So without further ado, it is my pleasure to welcome back my very special guest, Dr. Josie Geller. Well, it was so cool for me when the, you know, there was this explosion of self-compassion research that came out a couple of decades ago, you know, but it seemed like self-compassion was relating to, was referring to how we relate to ourselves. So when we did this motivational work, we learned that so much of what enhanced motivation was the way that we connect with our patients, you know, that having more curious, open, non-judgmental stance where we have as our purpose in life to get the best possible understanding of what's going on, how patient be more accepting of themselves, you know, those ingredients that were so important, you know, where there wasn't like negative consequences to not being ready where there was just an environment that was accepting of the individual that helped them to become ready. Self-compassion seemed to be a way of relating to oneself that uses those same ingredients. So rather than take out a baseball bat, when I notice that I'm doing something that isn't the way I want it to be, it's instead being open and curious and interested to understand what's going on better, you know, recognizing that, you know, not the only one who makes mistakes or who has challenges in life and having an aspiration to be kind, to be motivated to reduce distress and suffering in myself. So the self-compassion research started out with some of our staff who kind of exploded on the scene with this model that self-compassion is going to be attentive to our internal experiences, knowing that we're not alone when we have hardship and we're motivated to be kind to ourselves. But I think from a clinical perspective, the model that fits a little bit better with our patients, I mean, they both fit really well, is Paul Gilbert talks about compassion as a sensitivity to suffering with a motivation, and he really emphasizes the motivational component to relieve suffering. And so if we think about self-compassion, it would be having a sensitivity, which is similar to Christian nest definition of mindfulness, so just being tuned in to difficulties that I'm experiencing within myself, and then having motivation to try to reduce that suffering. And so when we first started to look at self-compassion in people who had eating disorders, we were amazed to describe, to discover, that it's almost like having low self-compassion was synonymous with having all the symptoms of an eating disorder, having high driver's symptoms, and having more episodes of binging and restricts with the eating. It was just almost like it would be impossible to have an eating disorder and to have high self-compassion from our original data. But more interestingly, we discovered, because in our program we're always doing continuous quality improvement research, so we're always looking at what do people look like when they begin treatment, post-treatment, and at Paula, up until for 20 years there was only one variable that predicted how much people benefit from treatment, and that was readiness. And the second consistent binding keeps coming every couple of years in the previous research. And for the first time, we looked at people's self-compassion, and we also looked at there's something called fears of compassion or barriers to self-compassion, and we looked at people's barriers to self-compassion as well at baseline and throughout treatment. And what we found low and behold was for the first time we had a second variable that predicted outcome in our treatment programs, and that was having barriers to self-compassion. In other words, for people who are saying for some reason, I think self-compassion is not a good idea for me. Those people benefited less from our treatment. So that got us really interested, and we started out by just trying to understand, well, what are the barriers that people have to self-compassion for people who have eating disorders? And we found that there were two types of barriers. The first one was we call it "meeting standards." It's having the belief that if I practice self-compassion, if I'm nice to myself and times it difficult, I'm motivated to be nice to myself, then that's like letting myself off the hook, and I'm going to become a slob and fat and lazy, and I'm never going to accomplish anything. And the people who love me based on my accomplishments won't love me anymore, so why would I practice self-compassion because I'm going to lose all the things I've worked on? Turns out that there's all kinds of data that refutes that, and that shows that that's not the case, that actually people who practice self-compassion achieve just as much as people who don't, in fact, they achieve more. It's just that rather than have their entire focus on achieving a goal and feeling really hard on themselves the whole time while they're working towards the goal, and then experiencing, you know, satisfaction for about 45 seconds after they get the goal, and then they get another goal, and then they're part of themselves so they get the next goal. People who practice self-compassion actually are taking pleasure and delight and joy in the process of learning or pushing themselves or doing whatever steps that involved in working towards the goal, that there's an intrinsic enjoyment of the process. So they are achieving, they just aren't having their well-being contingent upon achieving the goal. It's actually the entire process that is enjoyable for them, for them. So that's the first barrier is meeting standards. The other barrier we call emotional vulnerability, and this barrier is having, it's much more linked in feelings of vulnerability about if I was kind to myself would it put me in touch with emotions that I wouldn't know how to cope with? Would it, or maybe because I feel like I actually don't deserve anyone to be kind to myself? That's so unfamiliar. I don't know, maybe it's something that other people could have, but I don't feel like I should have it for myself. Or for some individuals, and this is really common. I don't even know what you're talking about. It's so foreign to me to be kind to myself. I'm so used to being critical that that's a totally foreign concept to me. And we found that people who have the meeting standards barriers that that was more associated with readiness early on in treatment and the emotional vulnerability barriers were more associated with the hard work that we do when we're really exploring the function of being disorder, trauma, and figuring out how do I need to care for myself that I don't really believe in so much? It seems like there's some parallels here between that those barriers to self-compassion and the function of the eating disorder behavior. Very much so. In fact, I think they're very linked. In many cases, as I understand the function of my eating disorder, it feels a little bit less scary for me to do the work of learning alternate ways of coping with difficult feelings and difficult experiences that I've had. So what are some ways that you all have found that are helpful for reducing these barriers? Yeah, so that was really the topic of our last set of projects was how do we reduce barriers to self-compassion when we know that they're linked to not benefiting from treatment when I have those barriers. So we just completed a couple of qualitative studies. One was in people who have recovered from the eating disorder. So they had, or were pretty far along in recovery. And we basically asked them, "What did anybody do?" They were very clear that one of, we have an experience of care-servant patients completed the end of treatment. And we found that they were consistently saying that one of the things that helped them the most in their recovery was developing self-compassion. That it was one of the most profound parts of their treatment experience. And when we asked them, "What did anybody do that helped you overcome your barriers?" I could summarize that entire project with one word, validation. So we actually wrote a paper called the Power of Validation. And it's one of the most profound, simple, but complex concepts that has come up in this area. So basically they said, "There were four levels of validation. And when people, whether it was clinicians or family members or people in my life, offered me these levels of validation, I slowly was able to overcome barriers to self-compassion and to become more compassionate and self." So the first level was two things. It seemed so simple. And we were unsure,"S students were working in therapy, we would know that this is critical, but basically making time and space for me." So really showing me with words and body language that you're not just asking a question so that you're ready to ask the next question, but that you're really listening to what I'm saying and offering a compassionate perspective. So whatever it is that I say, if I tell you that I'm struggling with something rather than having a neutral or possibly slightly critical way of looking at what I'm saying, that you're seeing that whatever I'm doing, it happened for a reason, and it's my best attempt at meeting a need that I have. And so when people in their life were able to do those two things, make time and space for me and offer a compassionate perspective, then the impact that it had on them was trust. That was the first building lock for overcoming barriers to self-compassion. I feel like I can trust this situation to really be open and talk about what's going on. The next level had everything to do with readiness. It's basically someone who took the time to truly understand and recognize my treatment needs. So they weren't saying, "Okay, you have this level of severity, you need this treatment." They were actually taking more time to understand, "What's my level of readiness? What would it be like for me to make changes? What's happened for me in the past when they made changes? What are my wishes right now?" So they weren't pushing me before I was ready, and they also weren't not noticing that I'm ready. And this is the time to give me some tools or some treatment options that I'm ready to benefit from. So when people took the time to understand and recognize my treatment needs to offer a menu of options like in the stated where we have a little home for each of the different combinations, the impact was cared for. So we get trust from the first level, cared for from the understanding mechanism that could be used. The next level after that was very often people would start to make changes. And people in their life would say, "Great, they're eating more. They're not been to get in perfected so much. We don't need to worry about them. We don't need to be checking in with them." But very often, they would say that at that point, they were in more distress than they had ever been because now they aren't using their eating disorder. And they felt even more vulnerable. But people were saying, "Great, we don't need to worry about them because their behaviors are shown that they're in your factory." And so what they said that they really benefited from there was someone recognizing, "Wow, I can see how hard you're working. I'm really noticing and impressed with the courage that you're showing right now." And I know that this must be pretty tough. Tell me about that and giving them an opportunity to talk about the challenges that they're facing. And pointing out their strengths, saying, "I've seen you use these strengths and other circumstances, and I can see those potentially helping you right now." Basically just noticing how tough and hard this is and recognizing their strengths. And when people did that, that level of validation, that made them feel empowered. So we got trust, cared for, empowered. And then the last level of validation, which was totally unexpected, we called it "walking the runway" finding. And those were words that one of the patients actually gave us. And it's basically the patient saying,"Don't tell me to practice self-compassion. Just like you're shoving a meal plan at me, telling me I should use self-compassion. Show me what it looks like on you." You know, let me look at how the fabric flows as you walk down the runway when you're wearing self-compassion. Show me that sometimes you make mistakes and that you practice self-compassion to not beat up on yourself and to be understanding the kinds to yourself and make yourself feel better. So they don't want to know our whole life story, but they want to know that we are also human, that we also have challenges, and that we also use these techniques. And when we rock with the runway, the impact that it had on them was inspired. So this is kind of like a crypt sheet of what the environmental components are that help people to overcome their self-compassion when they're in an environment of validation. And this is probably the one paper that we get the most attention from when I talk about it with our patients, that they're saying, "Can you give that paper to my parents?" or, you know, my loved ones, that it's something that they really resonate with and feel like it's an important part there, Jimmy. So do you think that this process is somewhat sequential? I described it in that way, and I think that, you know, people go in and out at the different levels, but generally speaking, at the very beginning, we really need to build trust and we really need to have the care for. And so I think those are more early on, and I think the empowering is more for once people are actively working on change. And then the inspired one actually occurs across levels. I think it's really useful for them to see that, you know, I'm not some, you know, person way up here telling you what to do, that, you know, I can relate, you know, we're co-humans and everybody has challenges and, you know, we're the same in that regard. And I'm not kind of in a totally different, perfect life situation that is so disconnected from me. So one of the things that I've always been unclear about is like, how, because from what I understand and tell me if I'm wrong, still a certain part of a lot of programs is some sort of ensuring eating a certain number of calories and that sort of thing. And that's always felt like what you're, like, there seems like a tension there. Yeah, how do you think about, but obviously, you know, you all have spent countless hours and lots of time to think about how to do this and deal with that tension. I'm just super curious about it. Yeah, well, it's all about getting buy-in that being interested in making dietary changes is something that I've decided will be beneficial to me. And when we have the readiness piece when they're saying, yeah, I can see that it's getting in the way of things that are really important to me. So now that I'm not being so hard on myself that I, you know, that I have this eating disorder and I understand that it's been my way of coping with trauma or difficult experiences and now I feel a little bit better able to cope with those things. You know, I can see that it's causing difficulties for me to be, you know, so focused on food or or physically unable to do things. So I really need the support to work on making dietary changes as well. And very often, of course, there's cognitive impairment when I haven't been eating enough. And so there's a combination of needing some nourishment while I'm doing this work so that I'm in a place that I can make use of treatment down the line. But it does definitely require a decision on the part of the individual that the life that I have now isn't the one that I want within for that I want there to be some change and an openness to receiving support to those changes. So it comes back to that story that you told a bit ago. I think you said, I don't know if you said something like eating your way into the closet, right? Eating your way, it like these are the things I love doing in order for me to be able to do them in a way that I can do them how I want to do them. I have to eat certain types of stuff just defunct it, right? And so that's the so it's doing working probably very slowly with a client to figure what that looks like for them. Yeah. And that really is I think what happens in our discovery program. So our residential treatment. You know, that program it's it's such a beautiful self-compassionate environment where people are given opportunities to finally unpack some of the difficulties and challenges that they've faced and have new ways of coping in different ways of managing emotions and the challenges that they have in their life. And the cost of admission for being in that program is to be normalizing ones eating and to be accepting the support to provide some structure around meal time. And so most people who come into the program have mixed feelings about that aspect of treatment. They know it's going to be challenging, but they also know that they're going to have access to you know opportunities to work on their skills and compassion and be able to have a different kind of life. And so and support to make the the eating changes as well. So you know it's it's like getting people to a level of readiness that that doesn't feel like a completely overwhelming proposition where they know that they're going to be receiving supports and it's worth it for them to start dipping their toast. And you know very often we also describe it not as you know you're committing to this forever and ever we're describing it as you know what have you brought to lose by experimenting by you know trying this out and you can always go back to where things were before but this at least gives you an opportunity to experience something. So what we've mostly been talking about is this in your writing a lot of times you talk about collaborative care and how I've come to understand it and then listening to you today a lot of what you're talking about is it's you're really making it clear that this is a very collaborative process and that's sort of the way to go and in your writing you compare it versus what is more directive care. You did some work which I thought was well on therapist or maybe I should say clinician I'm sure but helping professional compassion as it relates to them that the practitioner using more collaborative versus more directive care is one if you could talk about that a little bit. Yeah well just that it turns in terms of motivation and self-compassion we've discovered that our patients benefit enormously from a collaborative environment versus a directive environment and we just got interested in this because it was so clear to our patients that when we were more directive they felt like treatment was less acceptable they were more likely to drop out. That it was a it was it was setting up the very things that we wanted the opposite thing to happen. We wanted them to be feeling more motivated and more accepting that when we were overly directive and not including their needs that treatment was less successful. And so we just got interested in this and we ended up making a it was actually our patients who gave us the idea that it's not just what we say but how we say it that most matters and we developed some measures that would operationalize using a more collaborative versus directive stance and you know basically you know the the ingredients of collaborative care as we the client had these four components like basically not making any assumptions about the patients that you know about their reggaeness or about what they want to do. Having an aspiration to help with what matters to the client so not just make wanting them to do what I want them to do. Having a really clear framework and this was also something that kind of got some pushback at some point we called it a non-negotiable framework. So basically what is the what are the contingencies the conditions that we think are most likely to promote health and and positive behavior change and that when we had non-negotiables that were implemented in a certain way that is we had lots of conversations about them we we created them very thoughtfully so there was a good ration offer whatever we did we explained the rationale to the patients we include patient input in the non-negotiable framework. We were consistent about implementing them so we didn't do it one way with one patient the different way with another patient or one way at one point in time and different way at another point in time that just made everybody crazy and where we didn't have surprises people were always given lots of advance warning about what the non-negotiables were so that there were no surprises which tend to increase anxiety. That so when we had a clear framework that had those non-negotiable treatment components that that also made patients feel safe and more likely to experience us as being collaborative. So the difference also between collaborative and directive is that when we're being directive it is experienced as we're like the therapist trying to make something happen we have an agenda that we want the patient to do and they're kind of small and we're kind of big back here but in the collaborative model we're at the same size as the patient and what's up here is the non-negotiable framework that we've actually already agreed upon and used a really collaborative processing, inclusive process to determine what they are and our job is just to help the patient make the best decisions for themselves given the alternatives that exist in the framework and so we're really standing side by side with the patient and we do some really fun exercises where with clinicians where we experiment what happens if we try and make something happen this way versus this way and where the client has the opportunity to like basically talk through okay well let's say I'm on the inpatient unit and lunchtime has come and I don't want to eat my lunch we could say well you have to eat your lunch you know you committed to that or we could say well what were the what was the agreement that you came to when you came on the unit and then they say well I was I was half the lunch or I would have to replace the launcher okay well sounds like you're not really interested in doing the lunch how do you feel about replacing with the supplement well I don't really want to do that either and say something more about that and ultimately we say how can I help you make the best decision you know given this circumstances that you're in right now and so it's a very it's impossible to get into a fight with this person it's we we already have a shared agreement about what the conditions are and I'm just recognizing what would it be like let's say it comes down to well if I don't replace then I might be asked to leave because I'm medically stable right now so I might be asked to do program and so then it wouldn't be well then you better eat it it would be like okay well what would it be like for you now to do program and they might say something like well it would be a relief in some ways but or sorry yeah it would be a relief in some ways because it's hard being here but you know it's also been kind of nice to have a break from my life and to to get some you know healthy input and you know I feel physically better since I've been here and you know so actually it would be difficult and some ways to go home to and then my role as the clinician rather than say therefore you should do it it would be wow I can see there's some pros and cons to having this lunch and there's some pros and cons to leaving how can I help you make the best decision for yourself and that process of standing side by side and helping them to make the best decisions about their care rather than being in this place of authority where I'm trying to make them do something is experienced by patients as collaborative and much more conducive to both tyrannous and self-compassion. So we're basically looking at how to help all of us to create a climate where we're using that more collaborative approach. And you did some work looking at therapist compassion, self-compassion other compassion and its association with their use of more collaborative versus directive care, right? Exactly yeah yeah so it turns out that as clinicians are more self-compassion themselves and have more compassion for their patients they're more likely to use a collaborative stance which we know could be helpful. And we're doing a similar project right now in family members where we're looking to see what are the factors that support family members in maintaining a collaborative stance. So when I read that paper I really liked it. One of the things that sort of stood out to me is it's okay what are the characteristics and these aren't necessarily permanent characteristics but what are the characteristics of the helpers that are sort of facilitating or inhibiting their use of collaboration. And what I really liked about it is oftentimes we talk about approaches as like we're using a collaborative care approach or you know and it's so it's very much like this you know am I using this model this approach or am I not using this model or approach and the way that I read what you were what the work that you all did was more like it's not that simple as just like this is a kind of you know quote unquote you know collaborative program because you can be in a quote unquote collaborative program and really not be acting very collaborative you know or I would imagine there's lots of people in very sort of top down directive programs you know that the administrators of those programs would describe them in those sorts of I mean they might not use that language but that would be what they would be describing and I'm sure that there are extremely collaborative helpers in that program. So just sort of like trying to understand these is more what are the characteristics of the helpers that might lead them to be more collaborative or not and then that to me sort of also then says well if we can figure out what those are then maybe we can turn those knobs or target those knobs to help them to be more collaborative. Exactly yeah that's not so straightforward it's not just parroting some words it's actually the spirit of the interaction and that's what we're you know if you were to think of my entire program of research I think at the end of the day that's really what I care about the most is what is the the aspiration that I have what am I actually trying to have a curve in my relationship with my patient or maybe in my relationship with my colleagues and it makes me think a little bit of this other project that we did also with regard to learning about validation and the conditions that promote self-compassion in family members of adults with eating disorders it's it's the same thing where we ends up coming up with this conceptualization of family members typically start their journey with their loved one of adults with eating healthy probably with kids too to just fix eating disorder like just fix it make it go away you know which is kind of like us just eat the meal plan you know just you know go to full recovery and that family members over time of adults with eating disorders reached a different aspiration which was much more therapeutic and paradoxically helpful in their their loved ones recovery which was to have an aspiration to have an unrelenting connection with their loved one. Wow so it's starting from fix the problem and it's ending with I want an unrelenting connection with my loved one no matter what and that's a very different I'd be doing different things to achieve those two goals no fix it is like I might be being critical and judging you and telling you to eat things or just really encouraging you to eat things whereas in the aspiration to have an unrelenting connection it there would be taking a bit of a step back and maybe learning that I need to manage my own reactions and accept that maybe this isn't going to go exactly along the way that I would wish for it to go that's one step there's actually three processes that connect fix it to unrelenting connection so the first is just like having some support for myself and being able to accept and manage and change my expectations and the second part was recognizing that my loved one has some boundaries that I need to respect and also recognizing that I have some boundaries that I need to respect so sometimes there was a little bit of an over-envolvement and seeing that there's some benefit in letting my loved one do some things and also seeing some benefit that I need to look after myself too so I need to manage my reactions I need to respect boundaries and then the last piece that connects fix it to unrelenting connection is learning and practicing validation so coming to understand that you know being a really good listener you're offering a compassionate perspective you know not pushing them before they're ready saying empowering things to them or if you're minding recognizing how hard they're working when we're doing hard things and walking the runway if possible all of those things are helpful in fostering a better connection with your loved one and ultimately letting them know that no matter what happens with your eating disorder I'm going to be better so and paradoxically when we say that the eating disorder gets better so it's another one of those paradoxes like they were talking about in the beginning I think it's kind of a it's a beautiful phrase having it like I'm thinking about it sort of as a parent and I'm thinking like you know because you're always looking for these sort of north star ways of being a parent and you know it's like in a way that is like what a lovely kind of phrase for that right having an unrelenting connection with my loved one right with your son your daughter or whatever and that's like yeah that's really lovely so to get down to such a pithy but clear framework that's really nice yeah it probably applies to all kinds of parenting situations and life situations you know at the end of the day am I trying to like get what I want or am I recognizing that the most important thing here is you know our connections with one another at the end of the day that's what we're all going to care about the most right and I think that it's you know with with loved ones with folks with eating disorders that they're even though they might be more wanting to problem solve and directive and get you know a lot of that is born out of love and caring and whatever and then like okay so how can we take that energy that motivation and sort of shifted in a way exactly yeah and a big part of what supports you know those three things is you know the parents and everybody receiving support and getting some care for themselves like we we need to have our own well filled up in order to offer our best cells and to be able to keep our eye on the ball that at the end of the day the connections that we have. Right so being mindful of the time so so what I was going to ask you and it's totally up to you if you want to go there or not is sort of if you think we're at a good place regarding the DSM-5 eating disorder criteria I was like to just get a sense of where people who spend a lot of time thinking about these things where they sort of see the oftentimes potential limitations in the DSM. Yeah yeah I mean I think a lot of people are increasingly moving to you know sort of transdiagnostic approach to seeing that we do have these kind of arbitrary kind of criteria for what determines an eating disorder you know we've changed a lot of them we've taken things like menstruation out because that never applied to males in the first place and you know I think increasingly we're just looking at how much is someone's life impaired by what's going on with their eating. I'd say one of the biggest issues that's facing us right now is that up until now the treatment centers, tertiary treatment care in British Columbia anyhow has focused on Maurizia and Romania and there's always been a giant gap for people who have been eating disorder and you know so very often their lives are just as impaired but they haven't had access to tertiary level care and so that's something that's being considered moving forward. And then you know we've always had a catch all diagnostic criteria of other, Osved other specified feeding and eating disorders where you know because they don't meet the strict criteria of anorexia or bulimia but still could have you know tremendous life impairments that still important for us to have treatment that meets their needs and that would honestly look the same. We're not doing anything different because they don't meet all of the criteria. So are there one or two resources that you want to I always like to ask so I can include stuff in the show notes for people who want to learn more specifically about your work or other things that you want to point people to. Yeah I mean I think that for people who just want some quick and dirty techniques or things that would be useful I actually think that our most recent publications on validation could be really helpful and depending on how nerdy you want them to be we have one we have like a journal article version of power validation we also have a laid persons version that I can send both of those to you Dan. That people might want to look at you can also just look up look me up on the Center for Advancing Health and how most of the publications are there. Ladies and gentlemen Dr. Josie Geller. That's a wrap on our conversation about eating disorder's treatment. As I noted at the top of the show it would be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time[Music]