00:00:00

Intro

00:03:34

About Dr Millner

00:08:44

What food was like for her growing up

00:15:35

Her struggle with anorexia

00:21:16

Rachel's experience with treatment

00:25:52

Anorexia weight bias

00:45:03

Her supervision work

00:49:08

Rachel's group with Aaron Flores

00:58:44

Rachel's work with adolescents & family based therapy

01:12:52

Becoming a mother

01:21:26

Treating depression in her practice

01:30:53

A controversial take on treating anxiety in kids

01:42:09

Ending the show

00:00:00

Intro

Chris Sandel: Welcome to Episode 206 of Real Health Radio. You can find the links talked about as part of this episode at the show notes, which is seven-health.com/206.

At the beginning of September we’re going to be starting with new clients again and this will be the last time that we start with clients in 2020. Client work is the core of the business and is the thing I actually enjoy the most. After working with clients over the last decade, I feel confident in saying I am very good at what I do and when I reflect on the clients that have sought out Seven Health over the last couple of years, there’s a handful of areas that come up most.

One of the biggest is helping women get their periods back, so recovery from hypothalamic amenorrhea (HA), and this is often a result of under eating and over exercising, and is almost always connected with a fear of weight gain and a focus on being “healthy”. I’ve had clients regain their period after being absent for 10 or even 20 years, often after being told it would never happen again. Or clients becoming pregnant who had almost given up hope of it happening.

We work with clients along the disordered eating  and eating disorder spectrum and many clients wouldn’t think to use the term disordered eating to describe themselves, they just know that things aren’t right. With these clients there are symptoms that are commonly occurring; water retention, poor digestion, always cold, peeing all the time, especially waking multiple times in the night, no periods or bad pms, low energy, poor sleep, low thyroid and there’s also common mental and emotional symptoms, a compulsion for exercise, a fear of certain foods, anxiety, low mood or depression, poor body image and a fear of gaining weight.

At Seven Health, we believe in full recovery, we’ve had many clients that have multiple stays at in-patient facilities, where nothing worked but through working with us, they got to a place of full recovery. Many clients come to Seven Health as they want help transitioning out of dieting and so they can finally start to listen to their body. They’ve had years or decades of dieting and it hasn’t worked, but they’re struggling to figure out how to eat without dieting.

Many clients experience feelings of body shame and hatred, they’re determined to be a particular size and they feel frustrated or even angry by what they see in the mirror. They want to get past this and want to be present and stop putting life on hold. In all these scenarios, we use the core components of what Seven Health is about, which is science and compassion.

We focus on both physiology and psychology. Understanding how the body works and how to best support it. Also understand the mental and emotional side and uncovering someone’s identity and values and priorities and traits and beliefs, and looking at how these are helping or hindering with the change process.

So it’s these kind of clients that make up the bulk of the practice and I’m very good at helping people get to places with their food and their body and even with their life, that feels out of reach.

If any of these scenarios sound like you and you’d like help then please get in contact, you can head over to seven-health.com/help and there you can read about how we work with clients and apply for a free initial chat. This will be the last time we start with clients in 2020, so if you would like help then please reach out.

00:03:34

About Dr Millner

Chris Sandel: Hey everyone, welcome back to another episode of Real Health Radio. I am your host, Chris Sandel. This week on the show it is a guest interview and my guest today is Rachel Millner. Dr Millner is a psychologist in Pennsylvania and New Jersey, a certified eating disorder specialist supervisor, a cognitive behavioural therapist for psychosis, and a certified body trust provider.

She’s been practicing as a psychologist since 2005 and has been specialising in treating people with eating disorders throughout her career. She works with people struggling with all eating disorders and disordered eating as well as those trying to break free from diet culture.

Dr Millner is a fat positive provider, who works from a Health At Every Size lens (HAES). She provides weight inclusive care and works with people across the weight spectrum. Dr Millner is a certified body trust provider, with an approach which focusses on body liberation, both in her work with clients and in the activism and advocacy she does outside the office. Dr Millner frequently works with healthcare providers, who have their own food and body struggles.

She provides an accepting environment in which providers can speak openly without judgement and she is an approved supervisor through the IAEDP and offers supervision, both to providers working towards their CEDS and those who need supervision around working with people with eating disorders. In addition to her clinical work, Dr Millner speaks nationally on weight stigma, anorexia in higher weight bodies and about her own eating disorder recovery.

I’ve been aware of Rachel’s work for a number of years, if you listen to my podcast with Aaron Flores, which is episode 174, which came out in November of last year. We touched on the work that he and Rachel are doing together in supporting practitioners, who are dealing with their own struggles, with eating disorder relapse. Rachel is someone I’ve wanted to have on the show for a long while so I’m glad we’ve been able to make this happen. As part of this episode we chat about Rachel’s background and her own journey with eating disorder recovery and how this journey has really informed her work.

She was someone who was in a larger body and was suffering with anorexia but wasn’t able to get the support that she needed, or in many cases, believed and it was only later when her body did become much smaller that she was able to get the support that she needed. Because of this experience Rachel is very passionate about the topic of anorexia in higher weight bodies and we chat about this. We speak about her role as a supervisor and some of the areas she’s helping out practitioners and providers with how to be better and to do better. Rachel works with children and teens with eating disorders as well as adults, so we talk about some of the differences between these different populations.

We talk about family based treatment and family based therapy, and we talk about depression and anxiety, two areas that Rachel is regularly helping her clients with. With this, we cover some of the drivers for these mental health issues and some of the solutions that can help. So, let’s get on with the show, here is my conversation with Rachel Millner.

Chris Sandel: Welcome Rachel, thanks for joining me on the show today.

Rachel Millner: Thanks for having me.

Chris Sandel: I’m really excited to chat with you today and as I was preparing for this interview, I realised jus how many topics there are that I want to cover with you, there’s so many aspects of the work that you do that interests me.

So I’m hoping that we can touch on a many of them as possible and this conversation is probably going to jump around a lot, and go in different directions but there’s so many ideas and things that you cover as part of your writing, as part of your instagram, as part of the people that you work with, that I think are worthy of us talking about and touching on.

I guess to start with, I want to do what I always do and is just for you to give listeners a bit of background on yourself. A bio of sorts, who you are, what you do, what training you’ve done, how you spend your days, that sort of thing.

Rachel Millner: Sure, definitely. I am a psychologist, I’m also a certified eating disorder specialist and supervisor and a certified body trust provider, and I am lucky enough to spend most of my time working with clients. I spend most of my days working on, body liberation, eating disorder recovery, healing from food and body issues, disordered eating.

I also do a lot of consultation and supervision, so places that are currently working in a model thats not fully HAES informed, I’m getting to work with them and kind of coach them along the way, to becoming more weight inclusive, in their practice, and then supervising providers who are wanting to have more awareness of how to work with eating disorders and of course I always work from a fat positive, HAES informed lens.

00:08:44

What food was like for her growing up

Chris Sandel: So if we start more with you, what was food like growing up in your household?

Rachel Millner: Food in my household was complicated I would say. There was a lot of mixed messages, I have a younger sister and a younger brother and we were just in naturally different body sizes, so my body was a little bit bigger than theirs. There were a lot of mixed messages, that it was okay to eat if you were thin but not if you were bigger, there was a lot of focus on weight loss, and a lot of it was sort of in the name of my mom, in particular, wanting to protect me from weight stigma. What really she was doing was stigmatising me more and making me feel like my body was a problem, even though that was definitely not her intention, that was still the impact that it had.

Chris Sandel: Was that because she had experienced that herself and was like “Gosh I don’t want you to have to go through that.”

Rachel Millner: Yeah, that was a lot of it, she grew up in a family that also focussed a lot on her body and a lot of shaming around what she looked like, her body size. A lot of messages that in order to have a partner and be successful, that you had to be thin and had to be “watching your weight.” I think with this issue around food and body often times there’s this intergenerational trauma that is just handed down, from generation to generation. That was certainly the case in my family.

Chris Sandel: How far back did this go in terms of your memory? Do you have memories of as a kid where this wasn’t in play and then there was this realisation of “Okay, my body is an issue or weight is an issue.” Or as far as you can remember back, it’s just there?

Rachel Millner: For me, it’s as far as I remember, I found my baby book at one point, I think when I was in my early 20’s I came across it, in my childhood home, and my mom had actually written about needing to put me on a diet as an infant, it looked like the paediatrician had told my mom that I was gaining weight too quickly or drinking too much formula and so my mom talked about needing to cut back what I was taking in, even as an infant.

Chris Sandel: Was your mom then dieting through all of this as well, as you were a kid and a teenager?

Rachel Millner: She was, there was a lot of food rules, a lot of messages about what she wasn’t allowed to eat. She was a weigher at a diet company for periods of time when I was growing up. So there was definitely a lot of focus on her diet and the fear of food, there was a lot of vilifying  of different kinds of foods and that they were off limits in the house to certain people.

Chris Sandel: Okay. It sounds like to certain people, that also then creates this dynamic where you’re comparing yourself to other members of the household. It’s not like these are off limits for everyone, it’s only these are off limits to people in this body.

Rachel Millner: Exactly there were certain shelves in the kitchen that were acceptable for my siblings and my father to eat off of, and then there were other foods that I was allowed to have access to. I know that in a lot of families there’s a lot of focus on “health” and that only certain foods are brought into the household, in my family that was not the case. We had all different kinds of foods in the house, but the message was about who was allowed to eat the foods and who wasn’t.

Chris Sandel: In terms of your dad, where was he in all of this, in terms of his stance or his comments?

Rachel Millner: My dad never commented on my body, he dieted off and on, more so when I was later in my teenage years than when I was a child. He was working, they were a very traditional couple where my mom stayed home for most of my life, until I was later in my teen years and my dad went to work. A lot of this was coming from my mom, again all with the idea that she was trying to help. My mom was never intending to harm me, even though that was definitely the impact that it had.

Chris Sandel: How did this then play out for you as you were growing up? What happened in terms of the way that you ate or the way that you thought about your body as you then became older and into your teenage years?

Rachel Millner: Like most people who have food restricted, as I got older I figured out how to sneak food, how to wait until my mom was upstairs or out of the house and get food that I really wanted but wasn’t allowed to have. At that time I don’t think I was binging but I definitely was waiting for opportunities to get the food that I wanted and had a lot of shame around that, cause I had to do it in secret. So there was that feeling that I was doing something wrong, even though now looking back, I see that that was survival for me and a way to take care of myself.

At the time I thought I was a horrible person breaking these rules, as I got older and had more independent access, like when I started driving, could go out with friends, that gave me a little more freedom and I could eat more of the foods that I had wanted, I didn’t have to sneak around at home, I could sneak around when I was out of the house which made it a little bit easier. Throughout college I was able to do more of that.

Definitely at that point I started binging a lot more, then as I got out of college and into graduate school, I went into a twelve step program, focussed on eating which was really damaging for me and sort of set off my spiral into anorexia.

00:15:35

Her struggle with anorexia

Chris Sandel: In terms of it, you talked about it being your secret, were you able to talk to any friends about it, or even your other siblings about this?

Rachel Millner: No, there was so much shame around it, and at that point I had never heard of Health At Every Size. I didn’t have friends who were fat positive, I didn’t even know that that was a thing. So I thought that I was the only one, and the few times that I tried to bring it up with a therapist, or friends the message was still, “well of course you should be dieting, it’s not okay to be in a higher weight body ”

Chris Sandel: So at what point did you then start to seek treatment, or get treatment for what would then be thought of as an eating disorder? It sounds as though you were seeing a therapist, but a therapist for other things, when did the focus really become that?

Rachel Millner: I have always been in therapy, pretty much since I was a junior or senior in high school, and I definitely talked about issues around food and body but at the time, there was still a lot of focus on body size and not an awareness of having an eating disorder. As I got into college and then graduate school and beyond, that was when the focus really became more on eating disorder treatment.

Chris Sandel: What then did your recovery journey look like?

Rachel Millner: For me it was interesting, and I think this happens to a lot of folks who start in higher weight body, as I spiralled into anorexia and started losing weight, there was a long period of time that people were congratulating me and praising me and telling me how great I was doing. Even though I was pretty clear at that point that I had a problem, and would often say, “I think I have a problem.” and still people were very much looking at my weight loss as a positive thing.

Because for me anorexia did produce a significant amount of weight-loss, and I always like to be clear that is not the case for everybody and people can be very ill with anorexia and in higher weight bodies or body sizes that don’t change during their course of anorexia. But for me my body did change quite significantly and I did ended up in a very emaciated body, and it wasn’t until I got to that point that then there was more of a recognition of oh this is very serious, and then that treatment intensified and I was able at that point to really spend several years working on my healing, in terms of the acute part of my anorexia and then of course healing is a ongoing process that I think for me will be lifelong. That acute period was towards the end of graduate school and into the first few years of my career.

Chris Sandel: In terms of you recognising this was a problem, would you of labeled it anorexia? Or are you like “I think this is what’s going on” and then you would bring it up with someone else and because you weren’t at that stage in the body of what would be associated with, or stereotypically thought of as having anorexia, it was just pushed to the side, or brushed off, or talked about like that obviously isn’t the thing?

Rachel Millner: I knew I had anorexia and would say it and was told it cant be anorexia, that people with anorexia had to be thin or emaciated and so there’s no way that I could have anorexia. I knew enough at that point to know that I had anorexia, I was already out of college, into graduate training in psychology, had enough awareness to know what was going on but was told even when I said that very directly and clearly that this cant be anorexia, you’re doing something that’s “healthy,” you’re doing something that’s “positive,” making these “lifestyle changes.” Even though I was saying no this is an eating disorder.

Chris Sandel: I mean that’s such the sad side of this is, of like what would be dissuaded and thought of as a harmful behaviour in one body type, is then congratulated and suggested and promoted in another body type and is the exact same behaviours that are having the same level of damage, in terms of someones quality of life, in terms of someones health. Yet there’s this complete disconnect.

Rachel Millner: Exactly, I had the same eating disorder when I was fat as I did when I was thin. The eating disorder didn’t change at all, my body changed but the eating disorder didn’t change and yet as you’re saying, one was encouraged and one was treated and recognised as a problem. I think that happens all the time, that folks in higher weight bodies are not diagnosed, nobody even asks the question to say, “what’s going on with eating for you, whats your relationship with food like?” Then for folks in much smaller bodies the question is asked and the diagnosis is made, much quicker.

00:21:16

Rachel's experience with treatment

Chris Sandel: With the treatment centre that you then did go to when you were finally accepted as having ‘okay you do have anorexia’, was that a centre that was Health At Every Size informed?

Rachel Millner: So I did all intensive out-patient treatment, and no I had actually learned about health at every size and fat positivity towards the end of college and even though I was not able to incorporate it into my own life. I did know that it was out there, so my therapist at the time when I was going into more intensive treatment for the anorexia, was a wonderful therapist but I had to do a lot of educating about HAES, about fat positivity, and really teach her a lot of that.

Even though she worked a lot with eating disorders and like I said, was a really wonderful, gifted therapist, she didn’t know that information. At that point I was in a very very small body but even some of the comments that she would make were triggering or harmful to me and so I’m sure there was harm being done to anybody in higher weight bodies that was working with this therapist and I think still, lots of therapists in the eating disorder field, I don’t think she was unique at that time and unfortunately I think there’s still a lot of that happening in the field.

Chris Sandel: When you were giving that feedback to her, or even just educating her around this topic, was she open to that? Was she pushing back and challenging you? How receptive was she?

Rachel Millner: She was, I would say receptive, but I think where she often got stuck was around health and the healthism really worked it’s way in. There was an awareness of “okay people can be in different sized bodies” but there was often the “but what about health?” question. People don’t all have to be thin but we still need to worry about “health” and I think thats where a lot of people get stuck. Is where healthism is so prevalent and problematic and diet culture, because it’s such a shape shifting culture, kind of knows that the word diet is not, that people are being are being wised to what the word diet means and how harmful diets are. So have shifted to saying it’s a lifestyle change, it’s about healthy living and I think she had internalised a lot of that and was where she really got stuck.

Chris Sandel: So how long ago was this, that you were in treatment? I’m just trying to get a sense, because you said that things were bad then in a lot of ways, maybe haven’t improved that much. I’m just trying to get a sense of how long it’s been.

Rachel Millner: Sure, so interestingly I was in the worst of my anorexia towards the end of graduate school, during my internship and my post doc training. At that point I was in an emaciated body which like we were saying before, unfortunately that was recognised as a problem, whereas when I was in a higher weight body it was only recognised as a problem to be solved by loosing weight. In both my internship and post doctoral training in psychology, still nobody knew what to do, nobody asked any questions except to say like “well clients are commenting” but there was so much stigma, even in the mental health field, that I didn’t feel safe or comfortable saying to anybody around me that this is what was going on.

So I really, I  waited until I was done my graduate training, I was really clear on that, that I was not going for intensive out-patient treatment until I had finished my post doc. That was in 2005 and so it was at that point that I really intensified treatment and started focussing more on recovery.

00:25:52

Anorexia weight bias

Chris Sandel: Okay, and it’s interesting, when I look around and this is probably more of a reflection of the bubble that I live in. It feels like providers are changing and there is more of a Health At Every Size approach or they’re more Health At Every Size informed, but the honest truth is that I don’t know that, that is actually what is happening or I just have more of that in my newsfeed.

Rachel Millner: I know, it’s interesting, I have the same experience. I live in a very wonderful bubble of Health At Every Size, fat positive providers and colleagues and friends, and so sometimes walking out into the actual world can feel a little bit shocking, because I’m so used to this community of people who are really radical given the diet culture that we live in. I would say within the eating disorder field that things are both changing and staying the same, all at the same time.

I think there are pockets and communities that are in the eating disorder field that are really recognising Health At Every Size and working on incorporating weight inclusive care and seeing the harm that’s done when that’s not the type of treatment we provide. Then there are unfortunately large pockets of the eating disorder field that still focus on eating disorder and “obesity.” Or they talk about eating disorders and “weight management.” So there are still pretty significant pockets of the eating disorder field that are not recognising HAES, or weight inclusive care.

Chris Sandel: I also think that while that area, in terms of eating disorder recovery needs to change, thats kind of so far down stream, or so far at the end of the line, that actually for real significant change to happen it needs to be across, sort of all the health care system, otherwise you’re kind of catching people when it’s not too late, but you’re catching people past the point of which they needed to of been caught.

Rachel Millner: Exactly, I mean our healthcare system needs a radical overhaul. Every aspect, every part of the healthcare system, from training that providers get (and when I’m talking healthcare, I’m talking broad, so mental health, physical health, all providers), the training is steeped in fatphobia and weight stigma.

If that doesn’t change then recovery is never going to be safe for anybody, because people in higher weight bodies are being stigmatised and not diagnosed, people in lower weight bodies are terrified of gaining weight because they don’t want to lose privilege and be stigmatised and harmed. If the healthcare field doesn’t shift then the healing and eating disorder field isn’t able to provide care that is truly helpful and not harmful. There needs to be a shift from the top down, the bottom up, every which way.

Chris Sandel: In terms of diagnosis, with the latest version of DSM has the weight requirement been removed for anorexia? So are you now able to diagnose anorexia in all body sizes? Or you kind of have to do a work around, where you’re like okay I know it can occur in all body sizes but thats just not what the diagnostic criteria says.

Rachel Millner: So what they’ve added to the DSM is whats called “atypical anorexia” and what I usually say is that atypical anorexia is a diagnosis named by weight stigma. Because there’s nothing atypical about people in higher weight bodies who have anorexia. In fact more people with anorexia are not in emaciated bodies, than those who are. Yet we call anorexia in folks who are in higher weight bodies atypical. Which is just, we were just talking about weight stigma in healthcare, thats such a concrete example of where it creeps in.

I think that when the new DSM came out, just a couple of years ago now, actually probably five or six years ago, there was a lot of people in the eating disorder field, patting themselves on the back thinking that they had really changed the diagnosis of anorexia, that they took out some of the more concrete weight requirements. But they’re still in there and the diagnostic criteria is still incredibly weight biased.

Like I was saying, the addition of atypical anorexia, while it was progress because previously there wasn’t even a recognition that people in higher weight bodies could have anorexia. It’s not enough, not nearly enough and was not something to celebrate that this was included, it was something to say “Okay I guess this is progress and we really need to be pushing forward on this. This is still harmful to people.”

Chris Sandel: I don’t understand the US insurance system very well but, how easy or difficult is it to get insurance to cover anorexia, like atypical anorexia in a higher weight body, vs more kind of “classic” anorexia? Does it become more difficult for someone to actually get treatment?

Rachel Millner: I don’t think anyone understands the US healthcare system very well, even those of us who are trying to navigate through it, it’s very mysterious and set up to not cover anything and to be all about profit. It is much more difficult for people with the diagnosis of atypical anorexia to get insurance coverage, especially when you start looking at higher levels of care.

So if you move away from traditional out-patient therapy and start thinking about, a partial hospitalisation program or a residential program. Often times when they’re seeking approval from the insurance company to cover that, there is a question about weight and weight is considered in coverage. So there is a lot of fighting that has to be done and advocating in order to get coverage for higher weight people.

Often times there is an assumption that if people are in a higher weight body, they must have binge eating disorder and the insurance companies pushing for them to be in a binging eating disorder program, even when they have anorexia, so binging treatment would not be appropriate for them. So it’s very challenging and makes accessing care even more difficult for higher weight folks than it already is.

Chris Sandel: With the insurance, is one of the rules or at least one of the criteria for whether someone continues in treatment or is able to be discharged, is that around weight restoration and a specific weight? Because I could also imagine, there are a lot of people with again typical anorexia, to use the the DSM’s term, who get to a certain weight but are clearly not where they should be, from a behaviour perspective, or not where they should be from a health perspective but it’s deemed well if you’re at that weight you are now recovered.

Rachel Millner: Yes, that is definitely a part of it that focuses on setting a “goal weight” which is often this arbitrary, percentile that the insurance companies require treatment centres to set and not based on the persons individual body and healing, just based on a BMI chart that we know is bullshit. So it’s set based on that and when folks get to that point, there then is often a lot of push back from the insurance companies. That they don’t want to cover treatment even when there’s ongoing behaviours, there’s another layer of this within both the eating disorder field and our healthcare system, where if people are engaging in behaviours in treatment, that is often used as another reason to kick people out of treatment programs. Which is so counter intuitive and makes no sense but what ht insurance companies will say, and often the treatment centres themselves will say is, well you’re not making progress so you need to leave care.

So basically recognising that somebody is ill and really struggling, so we’re going to kick you out of treatment because this treatment isn’t working, instead of saying what is failing within the treatment centre or the treatment approach. The focus is that the client is somehow failing, and so needs to leave treatment and is often left with no care. Which is of course really harmful and hurtful and then that client is made to feel like they failed, they’re made to feel hopeless, that there’s not going to be a chance of healing for them.

Chris Sandel:  Yeah, which just is so frustrating because the whole trying to give someone an ultimatum, really doesn’t work because you’re then setting yourself up as an adversary to the person that you’re trying to help. It’s not about how can I be in alignment with you, it’s not how can we collaborate on this, it’s about okay, I’m telling you that this is the way that it has to be done and then if you don’t do it this way, then you have to leave. I just cant imagine that that really works for any large percentage of people.

Rachel Millner: No, I think what happens is, we recognise there is a power differential between providers and clients and then there’s an attempt to leverage power. Then clients feel powerless, they are threatened, their own autonomy in making decisions is taken away and who could possibly heal in an environment like that?

Chris Sandel: Yep, totally. Especially who could heal from something as debilitating and overwhelming as an eating disorder, it’s not you’re trying to, and even for something really small, and insignificant, that kind of a way of doing things, even if you get someone to change their behaviour in the short term, the likelihood is that they will resent that change and they’ll go back to doing it the way that they were doing it before as soon as someones not looking.

So in terms of the actual long term behaviour changer, I cant see how thats generally going to lead to someone not just relapsing or someone actually making the change in the first place.

Rachel Millner: Exactly, I think this goes to larger issues around mental health stigma and the belief that people who have a mental illness are not capable of knowing what their needs are, or making decisions around their own healing or their own recovery and that providers need to step in, take charge and tell people what to do because they don’t have the capacity to know for themselves.

We don’t trust clients intuition when it comes to their mental health, if they are dealing with a mental health diagnosis, which really makes no sense because clients know, we can trust them and we can help them tease out where is their eating disorder trying to get in the way and steering them in the wrong direction? Where is their voice? What are their needs? So we can do that collaboratively, it doesn’t mean that we have to say okay, let’s have the eating disorder run the show and let the eating disorder make all the decisions, but being in relationship with our clients and I think that often gets lost, that therapy is a relationship and it means two people showing up and working together on what the clients needs are, and how can we support them, not how do we tell them what to do.

Chris Sandel: Yep, and I would go further and say it’s not even just about mental health, this is about health in general, this idea that if someones failing with health, it’s because of a deficiency of information and if we just give people that information, then they’ll get on with doing it. It’s just not true.

In terms of a lot of things people know that they should be doing and they struggle to be able to do it for a whole variety of reasons and a lot of those reasons not actually relating to themselves but relating to, the environment that they live in, how they’ve grown up, social economics, like for all of these various reasons and when we get into the kind of talk that normally occurs of like, it’s just personal responsibility, I think it’s not just largely but really missing the point.

Rachel Millner: I totally agree, I think there is such a focus on, individual choice and individual behaviours and not recognising systems, not recognising trauma, not recognising lack of access, not recognising the impact of oppression. There’s a belief that if we hand information over to people, they should be able to incorporate it and if they’re not, we in our healthcare system here at least and it sounds like maybe for you as well that the response is well if we shame people more that’s how we’re going to get people to change.

So there’s this strange dynamic that happens where healthcare providers often use shame as a motivating tactic when shame never supports people in changing. You can’t shame people into shifting what they’re doing, and you certainly cant shame a system into changing. This needs to be a total, I think burning down the whole system and starting over. Rebuilding a system to actually provide care to the folks who need it the most.

Chris Sandel: Yeah, and it feels like there’s a disconnect with that as well because in some scenarios that is so obvious to people, like if you take a five or six year old kid, who is struggling with a subject at school, and you are like I think the best way of helping this child succeed is we just shame them. Every time they get a wrong answer we make them feel shame.

I don’t know if there are going to be any, or very few people who are like oh that seems like a really good idea and that I imagine that, that kid at the end of the year is going to be doing so much better in that subject. But for some weird reason you take it out of that kind of obvious realm and you put it into some other scenario and people somehow just miss that they’re doing the exact same thing.

Rachel Millner: Exactly, and I feel for healthcare providers, especially those who are doing more medical care because they’re asked to see people in, at least here, in 10 or 15 minute appointments. They’re asked to produce, productivity matters more than quality of patient care, they’re asked to make money, so in that 10 or 15 minutes, if they’re trying to cover 10 different things, sometimes what they feel they have time for is just to give a very brief lecture, with a lot of shame, and then send people on their way. I do know some medical providers that do work from a HAES and weight inclusive model and I talk to them, they are so much happier working from that model and if you have longer conversations with healthcare providers who are doing more weight normative care, and ask them, typically they don’t like it.

They recognise that they are likely doing harm, they recognise that they’re promoting weight loss and usually they can say something along the lines of, well I know diets don’t work. I think if we had more space to support medical providers we could shift a lot of them to being more weight inclusive, not everybody, I don’t want to minimise how much weight stigma there is, how much money there is in the diet industry, in the “obesity field,” so I want to make sure we’re naming that. But I do think that there could be more medical providers that would shift the type of care they were giving, if they had more information and spaces to talk this through.

Chris Sandel:  Yeah, agreed. If I had to see everyone in 15 minutes, while I wouldn’t be using shame, I don’t know how successful I would be. Because you cant really get into whats really going on and find out all of the details that then really allow you to then understand, okay how can we start to approach this, in a way that is specific to that person. You just hear a particular buzzword and then you’re like okay what is the thing that I do for that thing, because you’re limited, everything has to be surface level.

Rachel Millner: Exactly and I think healing happens in relationship and how do you have relationships when you have 10 or 15 minutes with somebody, maybe once a year, maybe more often, but there’s no way to truly build a relationship, that’s based on trust when contact is so limited.

00:45:03

Her supervision work

Chris Sandel: And so, one of the things you mentioned was doing work with providers and offering supervision, so I wonder with the providers or with the individuals who are wanting supervision from you, are there specific things that they’re personally coming to you and saying hey, I really need support in this area, this is an area that I really struggle with, are there things that stand out? 

Rachel Millner: That’s a good question. I would say that probably the two most frequent questions that I get from people who are wanting supervision, is either they work within a system that is not HAES based and they’re trying to figure out how to provide HAES and weight inclusive care within that system, so whether it’s a group practice or treatment centre or more of a medical model that they’re working in.

That they’re recognising the harm of weight normative care, they want to do something different and yet they’re finding if they speak up, they’re being met with a lot of resistance and they don’t really have any allies within their team. So they’re trying to figure out how they can incorporate this care thats so important and that they’re recognising as really needed within a larger system.

So thats often a conversation that we have, and then I think the other, maybe two things that people bring in. One is, how do we basically support clients in this healing, that okay I understand the tenants of HAES and I understand the concepts, I understand social justice, in a more generalised way but I don’t quite know how to take that and incorporate into therapy, because the vast majority of us who are trained as therapist and dieticians never learned any of this. In fact most of us were taught to keep, politics, social justice and personal beliefs out of the therapy relationship, so trying to learn, how do I actually incorporate this into the care that I’m providing is often a conversation.

I think the third thing people come up against, is okay I want to do this work with my clients but I haven’t really been able to do the work with myself and I need to do some healing and figuring out how do I find liberation in my own body and find comfort in my relationship with food and my body size in order to help clients in their own journey.

Chris Sandel: In terms of the more social justice piece and the activism piece and talking about that with clients, I know you have done the Body Trust training, is that something thats become bigger for you because of that, or no this was already a drama you were well and truly beating?

Rachel Millner: I think Body Trust helped a lot with that. I had started prior to my Body Trust training, grappling with how do I bring social justice into therapy more often and I had started to do it, but in a very tentative way, a lot of self doubt, am I doing something wrong, I’m going against my graduate training, so I felt like I was breaking rules. So being in the body trust training and really having more conversations around how to do that, and with other providers who were also working on shifting the way they were providing care, was really freeing and very helpful and provided me with a lot of support about how to do this work from a social justice lens and to bring that into therapy more consistently.

00:49:08

Rachel's group with Aaron Flores

Chris Sandel: Yeah, and with the third option you mentioned there in terms of providers who really haven’t been successful in doing the work on themselves and want to be able to get through that. I know you run a group with Aaron Flores about providers who have then relapsed or are struggling with their own eating disorder. Do you want to just talk a little about that?

Rachel Millner: Sure, Aaron and I started this group, gosh I guess it’s been a year now and we’re now running two sections of the group because there’s been such a high need for it. We started the group out of conversations he and I were having and then hearing from some providers who trusted us and saying that I’m really struggling here, and there is so much stigma in the eating disorder field that I feel like I cant be honest, I cant get help and I’m stuck.

For both Aaron and I, who both have a really strong belief that, I think our ethics are really aligned with the belief that providers are people too, and we get to struggle, and that acting like providers don’t struggle, means that providers struggle more. And that peoples lives are in danger because they’re not able to access care and that providers can hold all of it. We can be engaged in our own personal struggle and still show up for our clients in a way thats helpful and it’s interesting, you know the eating disorder field really challenges this, this belief that, well if a provider is actually struggling then there’s no way they can be helpful to clients and they should step away form their work, not see eating disorder clients, and we never hear that with other mental health issues.

Ive never heard somebody say, well if a provider is struggling with depression, they should not see folks with depression, thats just not  a conversation that happens, this only happens around eating disorders.

So when Aaron and I started this group, providers started to contact us, and it’s interesting because when providers contact us, questions they ask are, is there anybody else in my community who’s going to be in this group? Because I don’t want to see anybody I know or I’m going to have to share clients with. Because there’s so much shame and there so much stigma around it, and then when people are in the group, they’re shocked that not only are other providers struggling as much as they are, but that there’s a place to be open and vulnerable and nobody is judging them, that it’s all welcome. We really invite people to be honest and share where they are in their own eating disorder and for the providers who are in our groups, they’ve never been in a space like that before.

Chris Sandel: Yeah, it really is amazing the work you’re doing here. I had Aaron on the podcast and we had a bit of a chat about it then, and it was, yeah I definitely on this show before talked about the dangers of people with previous eating disorders getting into doing this work and doing so, where I thought it was something that needed to be talked about, but hearing you and Aaron talking about this as well, just realising that if that is the stance and that’s what people always hear, then if someone is struggling, they’re going to be secret about it, it’s going to be ongoing.

Eating disorders, as you talked about, in terms of you growing up, are shameful enough and something people will keep a secret but if this is the area that you then work in and you make your livelihood in and you see people in, there’s almost, maybe a feeling of surely you should know better and know how to do this. Of course thats going to keep people stuck and so upon reflection, I was like this is so important that this is going on and you guys are doing this work.

Rachel Millner: Thanks, yeah I think for both of us, we’ve talked about how fulfilling its been to offer this space and how honoured we both feel that providers are trusting us and contacting us, because it takes a lot of bravery to even reach out. There’s so much vulnerability in that and to say this is what’s going on for me, given the amount of stigma. I think what you’re saying is so true, providers end up struggling in secret and I really think we can trust providers to know, I don’t think any provider wants to harm their clients, and so if a provider is struggling in a way that they need to step back from their work.

I think we can support them in doing that, without telling them thats what they have to do or giving an ultimatum. Like we were talking about with clients, if it doesn’t work with clients it’s not going to be helpful for providers. So it’s not to say that providers don’t ever need to step back, but I think we can trust providers to know and to do their own work and their own therapy if we create spaces where that is possible. If providers can’t access care how are they ever going to know what they need for their own healing and how to best support their clients.

Chris Sandel: Definitely, and the difficulty is being a provider, they probably know the best people that they should be able to speak to, but then they can’t because they can’t let that person know that I’ve got this thing going on. So it’s like they have this real wealth of knowledge about, okay what would be the best thing to help me here? but they just feel like they can’t even access it.

Rachel Millner: Yes, I think that’s so true and so challenging to know what’s out there and who they would want to be talking to or what treatment centre they might want to go to but not being able to access it, for all different reasons, the stigma is just one of them, there is certainly other reasons. But yeah, so frustrating to be in that position.

Chris Sandel: And so I asked before in terms of what are the things that with supervision are coming to you and saying hey I need help in this area, but what about for you, are there things that you notice that people are doing that they’re unaware of that you’re having to point out and say hey I don’t think that this is so helpful or maybe you want to be reading a bit about this because I’m noticing this thing and that could be causing a problem.

Rachel Millner: Yeah I think it’s really important as a supervisor, or even as a therapist when I’m working with providers, to be able to give that feedback and to offer some guidance and some direction. But like I was saying earlier we do that collaboratively, we do that in relationship with one another. The care I provide is always trauma informed, so it’s not let me tell you this, it’s would it be okay if we talked about X, Y or Z? Would you be open to me offering a suggestion? How would it feel if I gave you a suggestion of a book to read? Or how would it feel if we talked about this topic? So making sure that I’m getting consent along the way, but I definitely will incorporate some suggestions or of course feedback and guidance as long as I’m getting consent first.

Chris Sandel: Nice, and are there other, specific areas that a lot of people have blind spots in, where you feel like this is the one or the two areas that I mention a lot that people just don’t necessarily think about?

Rachel Millner: I think there’s often a place where people get stuck in their process of incorporating HAES, it’s often the, okay I get this, up until the X weight, but what about the folks who are Y weight and so have mobility issues or this or that like then I’m not totally getting it. Or I understand if people are “healthy” but what if they’re getting feedback about certain illnesses and their doctors telling them they should be losing weight. At that point should we be promoting weight loss? So I think those are some of the areas that people bump up against their own weight stigma.

I remember listening to Sonya Renee Taylor from The Body is Not an Apology on a podcast and one of the things she was talking about was the point at which you start the sentence with yeah but, is the point at which you’re at your learning edge and you’re weight stigma or internalised fatphobia or racism, or whatever it is, is showing up and then you know thats the place you need to be doing your own work.

Chris Sandel: Yeah, I would say that what you described there was probably an area for me that took a while to fully grapple with and understand. So yeah I can understand how that is the case for other people as well.

Rachel Millner: Definitely.

00:58:44

Rachel's work with adolescents & family based therapy

Chris Sandel: So one of the things that you work with, in terms of eating disorders, is that you work with children and adolescents and so was this something that you’ve done since you started?

Rachel Millner: I’ve always loved working with adolescents, I think their spunk and their honesty and, there’s just something about adolescents that I really love working with folks in that age group and so thats been the case throughout my career that I’ve really loved working with that population. It’s been more recent, maybe in the past 8 ish years that I’ve really done a lot more work with adolescents and done more family therapy and family based treatment and sort of shifted some of the ways that I’ve worked with kids and adolescents.

Chris Sandel: One of the questions I probably should’ve asked before is when you started studying psychology, did you know that this was going to be your area of specialty or did you have an idea of something else?

Rachel Millner: This was always what I wanted to do. I think like a lot of people because of my own lived experience, this was the field that I wanted to go into.

Chris Sandel: So with family based therapy, can you just describe what that is if people aren’t familiar with that term?

Rachel Millner: Sure, I mean family based therapy is, so the manualised version is FBT or family based treatment and it’s really a sort of treatment where family is sort of incorporated into the care, and so parents, care givers, extended family, are seen as sort of equal members of the treatment team and tasked often with helping support their child in re-nourishment. So asked to do a lot of the re-nourishment process, supporting their kids in healing from their eating disorder.

I would say that I do more of what I think of as family based therapy and so I don’t do, manualised treatment. I do often incorporate family when its appropriate, I do often support care givers, parents with the re-nourishment process and believe that parents and care givers are the best support for their children and that wherever possible, keeping kids and adolescents at home is going to be better than sending them off to a residential treatment centre.

I think where I differ a little bit from manualised treatment is that I think about it as family therapy, so I think we have to look at the whole system and have to be working through some of the family issues, not just focusing on re-nourishing the child or adolescents.

Chris Sandel: Yeah, because that was the case, when I read Harriet Brown’s, Brave Girl Eating, and she did that with her daughter, Kitty. At least of how it was described in the book, so much of the focus was just on, okay, these are the things we do to get them to eat, to re-nourish but there didn’t seem to be a lot of exploration around, sort of wider issues or things that could be connected to okay what’s going on with this, as opposed to just oh well they got too low a weight, and that means that they were then deemed anorexic.

Rachel Millner: Yeah, I think there’s a divide in the eating disorder field between folks who think that eating disorders, especially anorexia is a biological disorder, that it’s a brain disease. That there aren’t contributing factors, so I think when you read stories where the main focus is on re-nourishment and the belief is okay I’ve re-nourished my child and now they’re going to be recovered, that’s really a focus on the belief that anorexia is a brain disease and that all we need to do is focus on re-nourishment and thats going to have somebody recovered.

I think most people in the field see eating disorders as being multifaceted and you know that there may be an aspect of genetics or you know, aspects of the brain that shift when somebody is malnourished and there are so many more sustaining factors and contributing factors, that all need to be treated and addressed.

Chris Sandel: Yep, definitely. With the therapy side of it then, are you doing therapy with many people in the room or are you having sessions separately with parents if that needs to be occurring, like what does it actually look like?

Rachel Millner: All of it, so often times it’s with many people in the room, where it looks more like traditional family therapy. Where the whole family system is in the room, if there is extended family that are part of care giving, they’re in the room as well, and we’re really working on family dynamics, family issues. How can we best support the person with the eating disorder and healing? Without identifying them as the one with the problem.

Chris Sandel: Yeah.

Rachel Millner: ‘Cause I think that happens a lot where there’s sort of an identified patient, and yes somebody needs to heal from their eating disorder and they’re not the problem. So it can look like really traditional family therapy. Sometimes I separate and do some individual sessions with the adolescent, and this is really age dependent, if I have a teenager I almost always do some individual work.

If I have a much younger kid who’s coming in, sometimes the parents are involved consistently and that individual work may not be age appropriate. But with teenagers I almost always do some individual work, and then I will often do parent only sessions. You know parents live in diet culture so they have their own internalised weight stigma and often times if their child started off in a higher weight body they may of been supporting some of the dieting and weight loss and then feel guilty that then it turned into an eating disorder. Or there’s often a fear that their child is going to gain weight and be back to the body size that they felt uncomfortable with to begin with.

I have a really firm, this is probably one of the few rules that I have as a therapist, but a firm rule that parents are not allowed to talk about their child’s body or eating habits in a negative way in front of their child. And so I will, if that comes up in any way, I immediately separate out and tell parents, listen this conversation cannot happen in front of your child and if you want to talk to me separately thats fine but you’re not going to say these things with your child present. And I really want to model that boundary and how harmful that is for a child to hear.

Chris Sandel: In terms of like the family based therapy, is it only for anorexia, ’cause thats how I’ve seen it talked about before, or can it be used for the whole gamut of eating disorders?

Rachel Millner: Most of the research has been with folks with anorexia and bulimia. I think there’s ways to use it for all forms of eating disorders, I think it needs to look different, I think the dynamics are often different. But if we’re conceptualising this more as family therapy, than manualised treatment, I think family therapy can work for most presenting issues and that family therapy is going to be helpful for most family systems, even if there’s not an eating disorder present.

So I think that family therapy is often indicated and if you’re looking more at manualised treatment it’s really just newer research thats focussing on BED, the original research did incorporate bulimia and anorexia.

Chris Sandel: And with your practice with children and adolescents, are you seeing them in higher weight bodies suffering with anorexia? Or they just don’t turn up as clients or patients because the parents aren’t thinking to bring them to you at that stage?

Rachel Millner: Both, often times, by the time somebody is getting to me that started in a higher weight body, they’re now in a lower weight body. But other times I am seeing folks in a higher weight body, because of the kind of work I do. And at this point most people who are seeking me out, know that I’m a HAES provider, know that I’m a fat positive provider. So, or at least partly seeking me out for that reason and so I do tend to see more kids and adolescents in higher weight bodies, than I think some eating disorder providers see.

Chris Sandel: And in terms of the adolescents you’re seeing, when would it be that you’re like I don’t think family based treatment or family based therapy is right in this situation?

Rachel Millner: Certainly if there’s any kind of abuse happening in the home, if there’s safety concerns. If the adolescent is saying that they don’t want it and they’re not consenting. My ethics are that, in at least in the state of Pennsylvania that 14 is the age of consent and so I try to really respect the adolescents autonomy and consenting and also work with that.

It’s not to say that I think a 15 year old is necessarily at a point to say I don’t want my family involved in treatment and that the family should never be involved. But I think if I’m going to build a relationship with the adolescent then I at least need to start from a place of respecting what their boundaries are and then we can work together towards incorporating the family, as appropriate. Because they live with their family, their family has an impact on them and so including the family, I think is important but I want to do that in a way that I can still maintain the relationship with the entire family system and not alienate the adolescent who’s coming in for care.

So I think, if parents don’t want to be involved, there are times when parents are saying I really don’t feel that this I something that I can be involved in, maybe they have their own issues going on that they feel like the capacity to be available for therapy or re-nourishment isn’t there, then that would be a case where family therapy would not be indicated. So we really evaluate case by case, the main one is if there is abuse or safety issues in the home.

Chris Sandel: Right, and given this work that you do and all the work that you do and your history, have you gone back and had conversations with your parents or with your siblings based on now what you know?

Rachel Millner: So yes with my parents. My mom and I actually went to therapy together for quite a few years, when I was in earlier parts of my treatment and we were able to talk about a lot of this. I was able to share with her how harmful and traumatising what she did was and she was able to take some ownership and also do some of her own healing work and recognise the ways that her parents had harmed her.

I think one of the challenges that often happens is that it was only at the point when I was emaciated that the fear was there, that led my mom to come to therapy, that it was suddenly my life was in danger, the panic had set in. So it was, we’ll do anything, I still feel really fortunate that I had parents who were willing to participate in my treatment and in my healing.

I was in my late 20’s at that time, you know, I had finished graduate school, I had my doctorate, I think a lot of parents might have said, look you’re an adult now, you’ve got to figure this out, and I had parents who were willing to show up and do some of this work with me. So I feel really grateful about that, I laughed a little when you asked about my siblings because, ironically my brother owns a weight loss company and does coaching and training and all this other crap. Helping, supposedly helping people lose weight.

Chris Sandel: Okay, wow. Thanksgiving at your home must be interesting.

Rachel Millner: Yes, you can imagine.

01:12:52

Becoming a mother

Chris Sandel: In terms of you, I know you’re a mother of two boys, so how has that experience of now becoming a parent impacted upon, how you do the work that you do?

Rachel Millner: I think, so I’m a single mom by choice and I chose exactly when I wanted to get pregnant and one of the things that was really important to me was that I was in a place in my own healing, where I was pretty sure that I could model intuitive eating and eating freely for my kids. Of course things things can change and people relapse and struggle, so I don’t want to say that just because I was in that place the day that I got pregnant meant that I was always going to be there but it was important that I was in that place at least in my healing process that I was pretty sure that I would be able to model that for my kids.

It was really important to me that I didn’t bring them into a home where dieting was present. And it’s been awesome to see how kids get this stuff, if you just talk to them about it from an early age.

So we have all different foods in our house. They are free to pick what they want, I trust their hunger and their fullness, I trust what they’re in the mood for, we talk about size diversity, they see my body, they see other fat bodies. We talk about stigma, we talk about oppression, in all different ways. They understand, when we’ve talked about gender identity, they understand pronouns better than many adults do, they will often point out to me things that are problematic on their kids shows which is horrifying how much weight stigma and heteronormativity is built into these kids shows, that are like animated and you wouldn’t expect it to show up.

One of my kids one day came to me and was like “Mommy, I noticed that all of my shows, the bad people are always fat and the good people are always thin.” So they pick up on that stuff, and were able then to have these conversations. What I have taught them, because of course they are confronted with messages from other families and at school and just out in the world about dieting, the way I frame it for them is that some other people just haven’t learned yet, that its okay to eat all kind of different foods and that bodies come in all different shapes and sizes. And that they’ve learned that already and some of their friends and some of their friends parents haven’t learned it yet.

I do advocate at school, so I send them at the beginning of the year with a note that says that they have permission to eat whatever part of their lunch or snack in whatever order and that we will be packing whatever snacks they feel like packing. That we will not be adhering to the classroom rules or guidance about what kinds of snacks to pack beyond, rules about like peanut allergies, things like that, but in terms of types of foods. There’s often that letter that comes home in the beginning of the year that says that we encourage snacks to be “healthy” and I let teachers know that, that we’re not adhering to any of those guidelines. And I also send a note and ask that my kids be removed from the classroom if there’s going to be any conversation around food, body size, health as people think its related to those things. And shockingly or maybe not shockingly I’ve had to do that since preschool, in preschool they had a local hospital program that would come in and talk about, I think they called it kid-fit or something and they talked about doing your X number of minutes of exercise, eating certain foods, so its been since they were like 3 or 4 that I’ve had to have them removed from the classroom during those kinds of conversations.

Chris Sandel: Wow, see I wouldn’t of even thought to do that, like I didn’t think that was going to be part of the conversation, so I’ve got a 2 and a half year old and we haven’t had to deal with any of that, in terms of going to school or nursery yet, but okay that’s interesting to know. So at what age did you start talking to them about all of this stuff?

Rachel Millner: Basically from the time they were able to have conversation, and obviously it looked different at different ages, but from the time that they were really young, we always had books in the house that talked about race and gender and activism and had different kinds of families represented. I taught them from the time they were really young about size diversity, so they’ve heard me talk about all of these things for their entire lives, this wasn’t a conversation that I waited to have. It’s just how we talk in our family and now they will be 8 in the end of July and now obviously our conversations sound really different to when they were 2 or 3, but the conversations have been happening all along. It’s wasn’t like one day I was like look let’s sit down and talk about all of this. They’ve just been hearing it as part of the way that our family works.

Chris Sandel: Do you find that when you’re working with children or adolescents that its easier for them to get on board with these messages, because they haven’t had as long hearing something counter to it or even within sort of younger kids today, there is more of an acceptance of gender fluidity and Health At Every Size or that there’s just more of an acceptance of difference than there was when I was growing up?

Rachel Millner: I think so, I think some of it depends on where people are growing up and what messages they’ve heard in their family and how much of the weight stigma they’ve internalised. Particularly if they’re in higher weight bodies, but I will say, recently over the past few months as there’s been, really a civil rights movement happening here and you know with black lives matter, its been really neat to see my adolescent clients, who are so ready to be activists, and are organising protests and really are just, they get it.

They’re standing up to their parents, they’re explaining racism, they’re explaining systematic racism, they’re telling their parents they’re wrong about things, like they’re out there and its so, you know there’s often a lot of stereotypes about this generation that’s growing up now and that’s not, the stereotypes do not hold true with the clients that I work with at least. They are eager to promote change and they see what’s wrong, it’s been harming them so they know a lot of the impact and they are so ready to speak up and be out there and create change.

Chris Sandel: Yeah, and I know you said there’s always talk about this generation, I think that happens with every generation, like if you talked to parents in the 1950’s they were complaining about their generation and yeah I think as you get to a certain age, you stop, or in a lot of cases you stop understanding what the struggles are that kids are going through. Or there’s these new changes, whether that be in technology or changes in terms of how people see the world, that then become so distant to what you experienced that you start complaining about, oh the kids today.

Rachel Millner: I think you’re right.

01:21:26

Treating depression in her practice

Chris Sandel: So there’s two areas that we haven’t touched on, that I’d really like to, that I haven’t touched on on the show before, or not in any great detail and that’s depression and anxiety. I know that you work with both of these, so let’s just start with depression. It’s a term that most people are aware of, but as a psychologist, how would you define it, or what does it look like.

Rachel Millner: I think similar to most mental health issues, depression looks different for everybody. I think with depression, it has often been something that’s labelled as an individual mental health issue. I think depression in response to a culture that oppresses people and marginalises people, is an expected response, that’s not pathological or something that should be stigmatised or seen as an abnormal response. So I don’t think depression is always about, sort of individual biology or brain chemistry, I think depression within this culture makes a lot of sense and that doesn’t mean that there isn’t an impact on brain chemistry, that often medication is very helpful, but people with depression present in a lot of different ways, some folks with depression, probably the stereotype that a lot of people have is like somebody who has a hard time getting out of bed, someone who feels really sad all the time, who might be having thoughts of wanting to harm themselves, having a hard time caring for themselves in different ways. Sometimes that’s what depression looks like and sometimes, people are going to work and raising kids and doing all kinds of things and still have really severe depression.

Chris Sandel: How often are people coming to you and saying I have depression or I am depressed? vs. you having a conversation with someone and pointing out that maybe this is what’s going on and they just never would’ve thought to use that label.

Rachel Millner: I think both, often times people come in and will say that they’re depressed. It’s actually more common that folks come in to see me that they are already aware of their depression than having awareness of their eating disorder. They think depression, there’s less stigma and it’s a little bit easier for folks to say I’m depressed, than it is to say I think I have an eating disorder.

So it’s pretty common that people come in knowing that they’re depressed. I do think that there’s sometimes this idea that my depression isn’t “bad” enough or “severe” enough to call it depression. So in those cases I will often have to bring up the possibility I’m wondering if you might be struggling with depression.

Chris Sandel: Yeah, okay. How often are you seeing someone that is suffering with depression that doesn’t have an eating disorder? Or it because you work in the eating disorder field that it’s normally that the eating disorder is always there and then depression is sometimes laid on top?

Rachel Millner: The vast majority of my clients are struggling with either an eating disorder, disordered eating, food and body issues that they want to work on, it’s pretty rare these days that somebody would come to see me just for depression. I don’t mean that just as to minimise depression, I mean that depression is the only presenting concern. Thats kind of rare for me, but typically, folks will have an eating disorder or disordered eating and also be struggling with depression.

Chris Sandel: I know you touched on some of them already, but what you’re saying is some of the other drivers for why this is occurring or at least drivers for why it is occurring for the people in your practice.

Rachel Millner: I think that people often feel isolated, that lack of community can really contribute to depression, I think lack of access can contribute to depression, I think for some folks, brain chemistry genetics can contribute to depression, I think that the systems that we live in can contribute to depression, trauma can contribute to depression, so there’s a lot of sustaining factors.

Chris Sandel: And are you seeing this as well in the same kind of numbers when you’re seeing the children and adolescents? Or it happens more or less vs adults?

Rachel Millner: Thats a good question, I would say that adolescents are a little bit more aware of depression and so I think, I probably see it a little bit more in adolescents but I don’t think that means more adolescents suffer more than adults do, I think adolescents may have a little more awareness, of how to describe it and talk about it.

Chris Sandel: When you’re working with this, are there ways that you find that are most effective and I know everyone is going to be different but are there particular practices or resources that you find most helpful? And I’m also wondering if you’re ever really just specifically treating the depression? Or its more okay when I’m doing the whole encompassing parts of whats going on with this person that the depression then in a sense will lift?

Rachel Millner: I think thats a really good way to describe it, I think we cant separate out different aspects of a person when we’re talking about healing. So often times doing more generalised healing or addressing trauma, maybe PTSD symptoms when we’re talking about increasing access, building community, doing a lot of that work in therapy, often reduces the depressive symptoms.

For some people I think connecting them with a prescriber to start psychiatric medication makes a big difference and you know, there’s still unfortunately stigma around that. But for a lot of people, it can really shift things for them, and so for folks that I think that would be helpful for, I really encourage them to meet with a prescriber and see if there’s medication that can help.

But I think a lot of the treatment is often doing more kind of general therapy that helps with the depression, sometimes we do get into more concrete, what are some ways that we can change just day to day stuff to shift mood a little bit? I think that can help in the short term but when i’m thinking like longer term healing, I think thats when the trauma therapy, building community, sort of deeper work is going to help.

Chris Sandel: And maybe this is going to be a difficult question to answer, but in the field at large how is it normally talked about with depression because you mentioned before, that talking about it as a brain disease and with medication things get better. And it feels like that was how it was explained for quite a while and now there’s a more broadening of understanding that there are a lot of other factors that go into this. So I’m just trying to get a sense of, is that just my thought that, that’s what everyone’s talking about or is that I’ve read books or listened to podcasts or whatever that make me think thats how the field thinks?

Rachel Millner: I think that you have probably been exposed to more radical thinkers, in that there’s still a pretty large percentage of people in the field that view depression as an issue around brain chemistry and that medication and cognitive behavioural therapy are going to produce long term healing and change and don’t recognise how systems of oppression, lack of access and all the things that we’re talking about contribute to depression.

Chris Sandel: And so for the people that you’re seeing, is it often that they’re seeing person after person after person, before they end up in your office, where those other methods had been tried and weren’t successful?

Rachel Millner: Yes, one of the more common statements I hear from clients is, I know all the coping skills, I’ve learned every coping skill, do not tell me another coping skill, I know them all and they haven’t helped.

01:30:53

A controversial take on treating anxiety in kids

Chris Sandel: And then anxiety, so kind of same thing as with depression, can you define what anxiety is like from a psychologists perspective or definition?

Rachel Millner: Yeah, anxiety really encapsulated a lot of different symptoms and there’s quite a few different types of anxiety. So some folks have more what we think of as generalised anxiety where there’s sort of constant anxiety going on, it’s not necessarily about one specific thing. Some people have anxiety where its more like a phobia, it’s like one specific thing that they’re really terrified of, OCD, obsessive compulsive disorder is a type of anxiety. PTSD can be thought of as a type of anxiety, so there’s lots of different ways that anxiety presents itself.

Chris Sandel: And with you again is this, are you seeing this more with the children and adolescents or its more occurring with adults?

Rachel Millner: I think, it certainly presents in both kids and adolescents and adults. I think the presentation is a little bit different, kids and adolescents are under so much pressure, managing school and social media and extra curriculars and being told they have to perform to a certain level and they have to get into college and theres just so much that they’re dealing with that contributes to the level of anxiety that theyre experiencing. Just the intensity of the pressure they’re under.

I think adults often experience a lot of anxiety for different reasons, trying to care for families, for themselves, trying to manage if they’re working and what that situation is like, the impact of trauma. I think any age group can have anxiety but I think the contributing factors are a little bit different depending on the age.

Chris Sandel: Yeah, I was listening to a podcast with Laurie Santos who, I think her podcast is called the happiness lab or something along those lines. She was talking about some research around, I think it was anxiety and comparing results from, say the 1980’s questions vs questions asked now and the difference in the anxiety of teenagers has just gone through the roof, the fear and worry about making enough money and getting a good job, and all of these things that weren’t so front of mind for kids or adolescents back in the 70’s and 80’s. It’s just so, as you say, so overwhelming and paralysing for so many kids these days.

Rachel Millner: Exactly, and I think that often kids and adolescents even though, I do think there is less stigma now than there used to be around mental illness, I think they feel like if they acknowledge anxiety they feel like they’ve failed. They feel like that haven’t been able to keep up and perform under pressure. They feel like they failed in some way.

Chris Sandel: Yeah, and also just the, everything is just constantly ongoing, so when I was a kid, I would go to school and when school was out, that was it and you’d go home. Whereas now there, its 24/7 because you’ve always got your laptop or your phone, and so especially for a kid who’s maybe having a hard time at school, and I would say for most teenagers it probably feels like they’re having a hard time at school, ’cause you’re just going through such an awkward phase, that’s never ending now.

Rachel Millner: Exactly, yep, there’s no break. There’s no time to step away, its just constant.

Chris Sandel: So in terms of dealing with anxiety, is this similar to dealing with depression where it’s actually dealing with all the other components and then that gets better? Or with anxiety in certain situations is it a little bit more targeted?

Rachel Millner: It really depends on the type of anxiety, so I do think that if we address some of the underlying issues and just some of the situational issues that, that can decrease anxiety and then I do think there are times where if somebody is experiencing anxiety, related to something specific, we can really intervene and do a little bit more targeted work.

I am and this is a little bit controversial depending on who you talk to with anxiety, but in terms of anxiety treatment, I am a big proponent of supporting adolescents in shifting expectations at school, I will often advocate on their behalf for reducing work load, decreasing expectations, giving permission to come to school late, like I think supporting adolescents in those things can be really helpful, in allowing them to be successful, in their schooling and to feel like their able to keep up, and feel like there’s somebody who’s on their side.

Chris Sandel: Yeah, I mean that makes complete sense. I mean for me, it feels like a lot of school is getting away from the real world of what we should be teaching kids, to then be able to be successful adults. And it’s a lot of passing tests and a lot of things that actually once its done and two years on, you don’t even remember what it was.

So you’re right, if you can be actually teaching kids you need to decrease your workload, you need to spend time getting more sleep or whatever it may be, thats going to be much more beneficial for them, not just in short term but also long term and throughout their life, than it is to teach them to get more grit and just persevere through.

Rachel Millner: Yeah, we expect kids to adapt to one style of learning and then if thats not the best style of learning for a particular kid, we label the kid as problematic and try to get them to adjust and be able to learn in one particular way. You know, kids are so different. One style of teaching and one style of learning is not going to work for every kid. I think what you’re saying is, we have such a good example of, over the past few months, that we’re in the middle of a global pandemic, kids are isolated, they’re scared, their lives have been turned upside down and while I do understand wanting to keep up with their schooling, you know, I saw it with my kids, the focus was on turn in the assignments, get the work done, learn the things you’re supposed to learn, instead of saying like how are you doing? Like this is a pandemic, this is so stressful, this is hard, this is scary, this is traumatising. Can we talk about that? Forget the math homework, let’s actually have a conversation about whats going on in the world and the impact it’s having on you.

Chris Sandel: Yeah, definitely. Even if the focus is on the school work, theres not enough of an understanding of how do we get kids to become intrinsically motivated around this? How do we get kids to understand what is their learning style, and what’re the things that they’re naturally pulled towards, because I think theres also this feeling that, if kids are left to their own devices, or if they’re left to be in charge, that they would do nothing and they would never want to learn anything ever again. And I think that, that is completely not true and that in a lot of ways, schools create a situation like that because it takes away a lot of the autonomy, it takes away kids natural ability to discover those things and kind of pushes them in a certain direction.

Rachel Millner: I completely agree. It shuts down the natural curiosity that kids come into the world with.

Chris Sandel:  Have you read much of the work of Alfie Kohn? he’s got a great book on unconditional parenting, but he’s also got a lot of other books around the problems with homework, and too much homework and the problem with gold stars and pushing kids, he’s definitely someone who’s had a real influence on me, in terms of thinking around this as a topic.

Rachel Millner: I haven’t read his stuff, I’ll have to check it out because it sounds really good and is a shift that needs to be made in school. I wish they would do away with homework altogether.

Chris Sandel: Yeah, and its interesting when I go and see, ’cause I’ve got a 2 and a half year old but obviously he’s not doing any homework but I go and hang out with friends who have children and the amount of work that they’re doing when they’re not even in high school, just blows my mind. I can not remember as a kid, when I was 8 years old having to do homework on the weekend. Or having to wake up at 6 o’clock in the morning to start to do an assignment, and it’s just, yeah it feels like that has changed drastically in the intervening years since I stopped being a kid.

Rachel Millner: Yeah, I agree. I see it with my own kids and I really get why the homeschooling population has grown so significantly and of course in order to home school there has to be a lot of privilege and a parent who can stay home, there’s a lot more to it. I really do understand why families who are able to access that type of learning, so many more have shifted to that because of you know exactly what we’re talking about, the pressure, the expectations, the amount of homework, all of it is just so intense.

Chris Sandel: Yeah, definitely. So look, this has been an amazing conversation Rachel, is there anything that we haven’t covered that you were hoping that we would touch on?

Rachel Millner: Thats a really good question. I don’t think so, I think we covered a lot in this conversation. I’m sure as soon as we hang up I’ll think of things, that oh we could’ve talked about this or that which is always the case in these conversations. No, I think we’ve gone through, we’ve talked about a lot, and I trust that we covered what we needed to cover.

01:42:09

Ending the show

Chris Sandel: Perfect, well the final question is and I’ll put all this in the show notes, where can people be going if they want to find out more about you?

Rachel Millner: My website is RachelMillnerTherapy.com and then my instagram is @DrRachelMillner and those are the two places you can find me the most.

Chris Sandel: Okay, perfect. I’ll put those in the show notes and thank yo use much for coming on the show, it was great to have this conversation. As I said at the beginning, there were just so many topics that I wanted to hear, and we were able to do all of them.

Rachel Millner: Thanks for having me on, like I was telling you in the beginning, I’m a big fan of the show so it’s been great chatting with you.

So that was my conversation with Rachel Millner, it was wide ranging and we touched on everything that I wanted to. So I’m glad she was able to make the time and we really got to do this.

That is it for this weeks show, as I mentioned at the top, we’re going to be starting with new clients again in the September time and that will be the last time for this year. If you’re struggling with dieting or disordered eating or recovery or body image issues, or any of the topics we cover on this show, then please get in contact. You can go to seven-health.com/help I will be back next week with another show, until then take care of yourselves, stay safe and I will catch you soon.