Episode 172: This week's episode is an interview with Nutrition Therapist and Certified Eating Disorder Dietitian, Marci Evans. We chat about body image - why the language we use around it is so important, how to define it, and some ideas for improving it. We also talk about the link between digestive symptoms and eating disorders, and how hypnotherapy can help in some cases.
Marci is a Food and Body Imager Healer®. She has dedicated her career to counseling, supervising, and teaching in the field of eating disorders. She is a Certified Eating Disorder Registered Dietitian and Supervisor, certified Intuitive Eating Counselor and Certified ACSM personal trainer.
In addition to her group private practice and three adjunct teaching positions, Marci launched an online eating disorders training for dietitians in 2015 and co-directs a specialized eating disorder internship at Simmons College.
She volunteers for a number of national eating disorder organizations including the iaedp certification committee and is serving as an eating disorder resource professional for The Academy of Nutrition and Dietetics. She has spoken locally and nationally at numerous conferences and media outlets.
She loves social media so tweet her @marciRD, follow her on Facebook and Instagram, and check out her blog at www.marciRD.com/blog
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Chris Sandel: Welcome to Episode 172 of Real Health Radio. You can find the links talked about as part of this episode at the show notes, which is www.seven-health.com/172.
Welcome to Real Health Radio: Health advice that’s more than just about how you look. Here’s your host, Chris Sandel.
Hey, everyone. Welcome back to another episode of Real Health Radio. This week on the podcast, it is another guest interview, and I’m chatting with Marci Evans.
Marci is a food and body image healer. She has dedicated her career to counseling, supervising, and teaching in the field of eating disorders. She is a certified eating disorder registered dietitian and supervisor, certified intuitive eating counselor, and certified ACSM personal trainer.
In addition to her group private practice and three adjunct teaching positions, Marci launched an online eating disorder training for dietitians in 2015 and co-directs a specialized eating disorder internship at Simmons College. She volunteers for a number of national eating disorder organizations, including the IAEDP Certification Committee, and is serving as an Eating Disorder Resource Professional for the Academy of Nutrition and Dietetics.
She has opened locally and nationally at numerous conferences and media outlets. She loves social media, so tweet her @MarciRD, follow her on Facebook and Instagram, and check out her blog at www.marcird.com/blog.
I’ve been following Marci for a number of years. I’ve always really loved hearing her conversations on other podcast shows, so it was long overdue to have her on Real Health Radio, which we get into. I’m going to just start this conversation, as I outline to Marci at the start what we’re going to cover, or what I hoped we’d cover, and we stay faithful to this. Marci is a wonderful guest, so I hope you enjoy this. Here is my conversation with Marci Evans.
Hey, Marci. Thanks for joining me on the show today.
Marci Evans: Thanks so much for having me. I’m really excited to be here.
Chris Sandel: I am really excited to have you on the show. There’s a couple of areas that I want to spend the majority of our time on, and these are areas that you personally have done trainings on.
There’s trainings on your site for practitioners. One of them is on digestive issues and eating disorders, and the other one is on body image. I’ve personally done the training on digestive issues and eating disorders, and it was fantastic. The one on body image I haven’t, but it is on my list to do at some point. So that’s the two main places I really want to focus on.
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Us recording this, this has been a long time coming. I think I originally got in contact with you nearly a year ago to come on the show, and at that stage, you were heavily pregnant, you were about to move house, and recording a podcast definitely was not the top of priorities. So how has the last year treated you? How has motherhood been? And don’t feel like you have to give an Instagram-esque picture of what it’s been like. I have a two-year-old and know that it’s not always plain sailing.
Marci Evans: [laughs] You know what, Chris? I was thinking about that this morning as I was mentally preparing to have this conversation with you and thinking about how you reached out. I guess it was a year ago, and you were so understanding as I was preparing for the last couple of months of work before my maternity leave, and things were feeling fairly overwhelming.
Then I actually ended up – I can’t even remember if I shared this with you – I ended up giving birth to my son prematurely. I ended up very, very suddenly developing preeclampsia and becoming very sick, very quickly. My son arrived, and we spent a very long time in the NICU. I ended up taking an extended maternity leave. I took more time off than I had initially intended to, and I’m very, very, very grateful that I was able to take that extra time.
So I would say the first two-thirds of the maternity leave were filled with time spent in the NICU. A very scary time, actually. There were, of course, moments of happiness and joy, but it was also very scary, very anxiety-provoking, in ways traumatizing – which actually makes me feel very grateful for my connectedness in the mental health profession and the amazing support that I had during that time.
I was able to take extra time for myself and for my family, and I’m really grateful to say that I was able to transition back to work this past summer. I’m very, very privileged because I’ve been able to work reasonably – of course, I’m working a lot, but at a pace and at a time that felt right. So I was able to come back to work and feel present and not feel distracted by what were the previous months of stress, and get to a really good place.
My son is doing very well. We live in Boston, which means we have our nation’s best medical care. We’ve had incredible providers. I’ve had wonderful support, and now I feel like I am finally to the place where we’re managing the normal challenges instead of the additional challenges of all these medical things we were working with. So challenges in childcare and sudden, unexpected things that always arise with having a child. It’s in juxtaposition with what was a really scary start.
I guess the silver lining is that it helps me to hold my perspective so I can laugh a little bit more with the poop explosions and things like that. [laughs]
Chris Sandel: [laughs] Definitely. What does an extended break mean? I think there’s a big difference between the U.S. system and then the U.K. system over here.
Marci Evans: Oh, that is so true. Thank you for reminding me of that. I would say most typical in the United States is – and not everybody is able to take this much time – 12 weeks. I had originally planned on 4 months, and so many of my colleagues were applauding me. “Good for you for taking all that time off!”
I ended up taking 6 months totally off. I was very separated from my work. I was not responding to emails, I was not on social media. I was really doing nothing work-related – which, for at least an American entrepreneur, is fairly unheard of. So yeah, that’s a great point.
Chris Sandel: Yeah, I think it’s pretty standard – I don’t want to make some assumptions over here, but a year is more the normal end of the spectrum, just because that’s how the system is set up. I always feel sorry when I’m hearing of people who have to, after 6 weeks and 8 weeks, go back to work and that’s considered the normal length of time.
Marci Evans: Yeah. We saw that in the NICU actually. I made some connections there with people who were back to work in that amount of time, in 6 weeks, 8 weeks. They were changing shifts with their partner as they were both working and trying to spend time in the NICU and care for other children. So I felt extremely grateful that I was able to full-time be present in the parenting process and in the recovery process.
We won’t go down the rabbit hole of this conversation, but there are some real problems, certainly within the U.S. system, which I’m more familiar with, around parental leave.
Chris Sandel: Definitely. Just because of my own experience with my partner, I know how long it takes to recover. It’s a big thing that the body has gone through, and 6-8 weeks does not seem like an amount of time A) for the human body to recover and B) for you to get into the new facet of life that is looking after a new, helpless child.
Marci Evans: Absolutely. I completely agree. I felt ready enough at 6 months to come back, and it was time for a number of reasons, but people would ask me, “Are you dying to get back to work?” and I’d say, “No.” And I love my job I really enjoy the work that I do, and I could’ve easily been content with taking more time and spending more time as a full-time mom.
But I’m also very fortunate to return back to a routine and work that gives me a lot of satisfaction, and to also have spent so many years doing what I’m doing, to move into something that I feel reasonably competent in and that felt familiar I think in ways was also a positive for me, going through so much that was unexpected. Like you said, transitioning to parenthood is always filled with things that are unexpected and new, and it’s challenging in ways that are unpredictable. So there was an element of, I think, the familiarity of my work that was in ways very grounding that I didn’t necessarily expect. So that ended up being, I think, a positive.
Chris Sandel: From my perspective, that definitely was a big help for me as well.
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We’ve started off in a way I don’t normally start off with a client, in that area, but why don’t you give listeners more of an official background on you in terms of what you do, who you are, what sort of training you’ve done?
Marci Evans: I’m happy to speak to that. I would just invite you, Chris, to interrupt me at any time, or interject, or invite me to move along faster or slow down, based on what you think might be interesting.
I am a registered dietitian. I have my undergraduate degree in Nutrition and Dietetics and did my 8-month internship in California, actually, at Cal State Long Beach, where I did a little bit of graduate work.
I was very, very fortunate in my schooling because I had the opportunity to do a rotation at an eating disorder treatment facility. Prior to that rotation, I really had a vague idea of what I thought I wanted to do as a dietitian, but it wasn’t until that rotation that I realized how resonant eating disorders work was for me. There were aspects of it that felt really, really interesting. What I couldn’t have named at the time, but have the understanding now, was more of the psychological lens of food and eating and relationship to food and body. I really loved that it was multidisciplinary in nature.
So I got to get a little bit of a taste for it during that rotation, and that really changed the trajectory of my career. It was at that point that I was introduced to the book Intuitive Eating for the first time and was considering concepts that had not been introduced to me previously.
When I wrapped up my internship, I ended up taking a job. I was living on the West Coast in the States at the time and was doing preventative wellness work, but was really weaving in my own self-learning around intuitive eating and size acceptance and weight-inclusive care. After that first job, I ended up taking a pause because I moved abroad. Actually, I lived in Germany for a year and a half.
It was during that time that I really went into full self-study mode and immersed myself in eating disorders counseling work, weight-inclusive practice, intuitive eating, and that really informed the rest of my career and where I’m at today. I ended up moving back to the States, out to the East Coast in Boston, where I pursued my Master’s degree and was able to do a really cool program at Northeastern where I was able to kind of create my own Master’s degree. I blended together eating disorders counseling along with business entrepreneurship.
As I was wrapping up my Master’s degree, I was juggling several things at the time. I was working at an athletic club, where I was trying to work in a way that was in alignment with my values but was really feeling like it wasn’t – no big surprise – the right audience. [laughs] They were like, “That’s all nice and good, but I really wanted you to help me lose those last 10 pounds.” But I was also working at an eating disorders treatment facility at a higher level of care, and I was starting my private practice. There were 6 months there that were a really intense juggle.
But in that time, I was getting more and more clear about what I was passionate about and how I wanted to spend my time. The past decade for me has actually been in private practice, providing nutritional counseling, individual counseling for folks in recovery from eating disorders, disordered eating, and those who might not be diagnosed with an eating disorder, but have a long dieting history.
In that time, I have become very passionate, as you indicated, about empowering other dietitians to do this work. I see the role of the dietitian as being integral, and we often lack training in this field. So I wanted to make training more accessible to registered dietitians. I think it was also the entrepreneurial part of me as well.
I designed currently three online courses. I’m really heartened to hear that you learned some things and found the training on digestive health and eating disorders useful to you. I’d be interested to hear about your experience there. I provided a general training on Nutrition Counseling for Eating Disorders, and as you mentioned, another training with my colleague Fiona Sutherland on body image and doing body image work across the spectrum. It’s not with a focus on eating disorders, and it’s certainly available to all clinicians. These aren’t trainings for dietitians specifically, but it is with that lens in mind because I am a dietitian.
My most recent project that has been ongoing for the past I guess 4 years has been at the academic level, working at Simmons University here in Boston with my mentor and my colleague, Lisa Pearl. We had been invited by the Simmons Dietetic Internship to collaborate together and to build a specialized dietetic internship around eating disorders, which is the second in the United States. It’s been an honor and it has been a joy, and it has been tremendously exciting to build specialized rotations for young students to get training in eating disorders.
And then we have also the opportunity to teach a graduate-level course each semester on Nutrition Counseling for Eating Disorders, and it is profoundly gratifying to see our students go and make differences in their own realm and joining the field. My hope is that we will continue to train dietitians to not only know how to work in the field of eating disorders, but continue to elevate the role of the dietitian, which I think unintentionally in ways has been minimized over the past two decades in the field.
So we’re trying to reshape a bit the role of the registered dietitian and what we have to offer in nutrition counseling, which is to do far more than provide an exchange-based meal plan. You can hear how I could get into a bit of a soapbox there, so I’ll pause and let you talk.
Chris Sandel: There’s a lot you said there that I want to go back through. It’s interesting for you in terms of getting into eating disorders, and as an eating disorder dietitian, so early on in your career. For a lot of people who I’ve had on this podcast who are dietitians, that side of things seems to come much later, maybe after they’ve been doing weight loss with people for many years and they have some light bulb moment or something happens that makes them change course. But it almost sounds like, pretty much from the word ‘go’, you were heading in that same direction. Is that right?
Marci Evans: Yeah, that’s accurate. I think I am very fortunate that I did have the unique experience of being exposed so early. Certainly, that really has informed my entire career. I never worked within the traditional weight-centric model.
Even in my first job, where I was trying to figure things out – I was hired in this preventative wellness department at this outpatient medical clinic, but I really happened to be working with an exercise physiologist who also had been introduced to intuitive eating. So we designed a whole program that really tried to approach health and wellness from a non-weight-focused lens. Not to say at all that we did it perfectly. I certainly would have done it very differently now, being much later in my career. But I was doing the best with the information that I had.
I think that is different than the vast majority of health professionals, but certainly for dietitians.
I had my own experiences in high school and college or at university, where my relationship to food was not at its best, and I had my own ways of struggling. I never had a diagnosable eating disorder, but certainly had enough dysfunctional ideas about food and struggles with eating – particularly my freshman year of college.
I worked through that through my college years in a way that was almost in alignment with intuitive eating, but didn’t know about intuitive eating. So I do think I had a bit of a bias in my own lived experience of reading a book that so reflected what was very positive and healing for me, and moving away from the restriction mentality, that it clicked very, very quickly. I read the book for the first time, and I was like, oh my gosh, this is laying out, and so well-articulated, things that I had figured out and muddled my way through over the past few years.
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Chris Sandel: That was going to be one of the other questions, just thinking about what your experience with food had been. It sounds as though you said late teens going into college/university, there was more of an issue. But in terms of growing up, how was food in your household? How were siblings or parents and their relationship with food?
Marci Evans: I am extremely fortunate. I grew up in a home with a mom who certainly has thin privilege (however, we know that thin privilege does not protect necessarily a person from dieting and body hatred). But my mom really had a very easy relationship to food. We did not have dieting language or dieting in our household.
In fact, I look back and laugh at how nutrition was just not high on the priority list. I would say we always had family meals, wonderful, warm family meals, but my mom would make things like chicken Doritos casserole, and Shake ’n Bake with white rice and we’d pour soy sauce on it, or ham and scalloped potatoes. We most often ate really sugary breakfast cereals. I don’t know how well this will translate to your international audience, but I was eating Lucky Charms and Froot Loops and Eggo waffles for breakfast, and my mom didn’t like packing lunches, so we ate school lunches.
No foods were off-limits. I would walk myself with my friends to the convenience store and use my two dollars to buy chips and candy bars and sit in the aisle, reading teen magazines. I look back and it really gives me a big smile on my face, because I was so uninhibited around food.
But it wasn’t until my preteen years I really got into dancing and the dance world. So that’s where things started to get a little bit confusing for me, because I had this very free relationship with food at home, and even my friends, and on our dancing breaks we’d go to Burger King and eat chicken fingers and French fries. But then we began to get these messages about food and bodies by our dance instructors. I think that’s when things started to get a little bit muddled inside of my own mind.
Then you start to get exposure to alternative ideas socially. When I look into moving into those teenage years where things started to become a little bit more difficult, it had much more to do with social exposure to what other girls were doing in the dancing community more than anything else.
But I know that I have a lot of gratitude with the ease in which I was raised around food because I think it was very, very, very protective for me. I think I have naturally a lot of the temperament that would make me vulnerable to the development of an eating disorder, so I see my family life as being incredibly protective for me. I have a lot of gratitude for that.
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Chris Sandel: How did you then become interested in deciding to become a dietitian? Are you naturally the science-y kid? Was it that preoccupation with food at that point in your life that put you in that direction?
Marci Evans: It’s a great question. I think it was a couple of things. I was naturally the science-y kid. I’ve also always been incredibly social and had a natural interest in working with people.
When I was in my later high school years, I started thinking a little bit about “I’m going to be going to college; what do I want to study?” I had learned about occupational therapy or physical therapy from a movie I had watched, and that was really intriguing to me. I was certainly aware of maybe nursing as a potential profession. But I realized that I had a very, very, very limited bandwidth for dealing with things like needles and blood and bodily fluids. [laughs] I don’t think that I have the nervous system to handle working in the medical field, and I really did not like the idea of medical school.
There was a little bit of that food obsession piece that was creeping in in my later teen years. I loved to bake. I baked cookies all of the time for friends and family, so I definitely had an interest in food. So there was that piece in there.
But what was really the main pivotal point for me was a conversation that I had with an uncle, who I’m still close to, who has Type I diabetes. He said, “You know, Marci, you’re getting ready for college. What do you think you want to study?” I said, “I don’t know. I really like science and I want to help people, but I don’t know about becoming a nurse.” He said, “You should think about becoming a registered dietitian.” I said, “I’ve never heard about that. What is that?” He said, “I work with a dietitian and she teaches me how to dose my insulin and how to keep my blood sugars in control, to keep me healthy.” He showed me his insulin pump.
It was like this whole world opened up of possibility. I could talk about food and health and help people and science. It was so exciting to me, and – this sort of reveals my age a bit – I went home and I drove myself to the public library and I checked out a book. [laughs] On registered dietitians. Google was not a thing. I read the book, and I went to my first day of my freshman year and I knew exactly what I was going to study.
So from Day 1, I was very clear about becoming a dietitian. However, I will say it was fraught. During my undergraduate, there was a time when I thought, “I’m in the wrong major. I hate my food science classes. I don’t really even particularly enjoy learning about community nutrition. I really like my anatomy and physiology courses. Should I change majors?” It was a bit of a bumpy rollercoaster. But I decided to stay the course.
But as I mentioned, I was doing this very cool dietetic internship where I had exposure to so many different options as a dietitian. Every rotation, I said, “That’s interesting and I have no interest in pursuing that.” I was feeling a little frantic about it because I thought I wanted to be a clinical dietitian, and in my clinical rotations, I really did not excel at all. I felt very discouraged. I often felt confused. I didn’t feel very effective. I think part of it was I didn’t get great training in my clinical rotations. But I thought, “Oh no, this is what I imagined myself to do, and now that I’m doing it, I don’t like it at all.
Gratefully, I had randomly been assigned to this eating disorders rotation, and it was like it all clicked together. I realized that as much as I did and do still love science, I am also very, very interested in psychology and relationships just as much. So it for me ended up being the perfect blend, but I absolutely did not know that when I started as a student.
Chris Sandel: What you’re describing there is the part that I like as well, where it is the science-y side of things in terms of understanding food or understanding physiology, but it’s then more the human aspect of it, the messy side of understanding why people do what they do and how they think and the psychology of it and bringing those two things together – that is really exciting for me. If it was just straight up nutrition, I find that pretty dry.
Marci Evans: Yeah, I’m right there with you. I love, as a dietitian who works in private practice, that I have so much latitude in how we can explore food. I think I would be feeling burnt out and probably would have left the field if I was in a position where it was really much more solely focused on nutrition and nutritional science or portions of food or designing meal plans. I think that there is a place for that, absolutely, and not to minimize that part of the nutrition profession. But knowing that there is so much more to explore and to be curious about is very exciting for me.
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Chris Sandel: You said that it was a little bit of a bumpy road as you went through that – and maybe some of that was to do with you not knowing where you wanted to end up, and maybe some of that was to do with the actual course and what was being taught or how it was being taught.
You said before about showing your age – you obviously studied quite a while ago. Maybe this is just a ginormous question that would take a whole podcast to answer, but do you think dietetics is getting better in terms of the training that is being offered and what you would like to see be offered based on your preferences around Health at Every Size and intuitive eating and all of those leanings?
Marci Evans: My guess would be that on the whole, there have likely been some positive strides, but I still continue to feel so discouraged in how little training there is, certainly in exposure to concepts like weight-inclusive care, to intuitive eating, but also in general, just the counseling process.
I train dietetics students at the graduate level. Often they’re in their first or second year of their Master’s degree. Without fail, the feedback is “How am I not learning this until right now? How is it that I have gone through 4 and 5 years of my training and I have never once heard these things?” There is a part of me that feels a little bit of – I’m not even sure what the exact emotion is; maybe trepidation or my own anxiety – I’m really shaking things up for them in a way that is unsettling and I think perhaps can feel confusing, because they’ve been trained in a very specific model, and then I show up and really shake things up.
That saddens me. I yearn for training of dietitians that certainly introduces concepts that are more embodied rather than just top-down head knowledge. We are so grilled into the science piece – which is incredibly important, and it is missing the other components of appetite, of thoughts and beliefs around food, about how we connect to other people. It is just totally and completely devoid.
In fact, I was just speaking at a conference a couple of days ago, and I was speaking with my co-presenter, who works in an academic setting in Canada, and I was fascinated by what she shared. It was this little anecdote that she had all of her students draw a picture of the ideal dietitian, and one of the students drew a giant brain with open arms extending out from the brain, demonstrating openness to learning and knowledge – which on the one hand, I love the visual of open arms. But this idea of the perfect dietitian is this bodiless brain did not escape my attention.
I was giving a talk on body image, and I was like, oh my gosh, this is so symbolic of the ways that dietitians are taught to be. It’s this very intellectualized approach to food and eating. It makes me sad. I think we have a long way to go.
Chris Sandel: I would agree with you totally on that. When I think about myself and using the books I read as a proxy, if I go across the 10 years, 11 years, however long I’ve been doing this, at the start, it was so much more heavily skewed towards the science and books around food and all of that.
Now I could go a year and barely read a book on that topic because there’s so many other parts I want to read about. A lot of what I focus on now is just how to be a better practitioner, how to be better at being in a room with someone, how to be better to have better conversations and to have difficult conversations.
All of these really important facets of being a dietitian or being a practitioner if you’re sitting with someone one-on-one and having to help them in whatever way they need help. Because it’s not about me as the expert just telling them all of these great ideas. It’s a lot more of a messy process than that.
Marci Evans: Oh gosh, I couldn’t agree more. Yes, we have our training in anatomy and physiology and nutritional science and what happens with digestion and all of that, and those things are wonderful – and it becomes really meaningless if we don’t have the capacity to connect on the human level and if we don’t have the capacity to really trust that our clients or our patients have embodied knowledge and lived knowledge that is as valuable, more valuable, than what we bring to the table from the nutritional science lens.
It is that capacity to connect and be in relationship, and the give and the take, and the listening – being able to actually really, really listen. And those are not skills that I was taught in any way, shape, or form as a student.
I remember very clearly the very first patient I saw. I had finished my dietetic internship, hours of training, and I was terrified because I had no idea how to be in a room with another human being, how to do the job of a dietitian. I knew the science; I did not know how to be a counselor. So that is a big piece of what I try to bring into my trainings: how to have conversations and be in relationship with, and how to support and help people.
Chris Sandel: Definitely. I think we could stay on that topic for quite a while, but I’m going to just shift into the two main areas that I mentioned at the top.
Marci Evans: Wonderful.
00:35:10
Chris Sandel: Let’s start with digestive complaints and eating disorders, and maybe with the basics with that. Why are digestive issues so common with eating disorders? And not just eating disorders, but in the recovery of eating disorders, because it’s not like the symptoms disappear simply because someone starts the recovery journey.
Marci Evans: Yes. Thank you so much for the lead-in and for framing it in the way that you did, because that’s incredibly accurate. Gosh, I’m having about three different streams of thought.
What piqued my interest as an outpatient provider is that I am working with people, typically, through the latter stages of their recovery. Perhaps they are less symptomatic than a client would be, say, at a residential level of care. Historically, the party line from the eating disorders community is “just stick through the refeeding process, reduce your eating disorder symptoms, and all of the GI stuff is going to get better.”
I was sitting with my clients and I’m like, this is just not their experience. This is continuing to have GI issues long after they’re no longer engaging in restriction or binging or purging of any kind. I was so invested in trying to better understand these digestive complaints because it was almost universal in my practice.
I was having a conversation with a close colleague of mine, who is a digestive health dietitian with an interest in eating disorders, and I really felt I was an eating disorder specialist with an interest in GI complaints. So we started doing this cross-supervision with one another, and she began sharing with me data and information that was so jaw-dropping and so important, I said to her – her name is Lauren Dear; she’s phenomenal – “Lauren, we have to start speaking about this, because this is such an issue for our field, and there’s so little discussion on it, and you have such important information to share.”
That’s when I did really, really, really deep dives into the literature to understand the intersection. That’s the thing that I’m really, really curious about, is this intersection. One of the common questions that people have is “do GI issues make a person vulnerable to an eating disorder, or does the eating disorder cause the GI issues?” The answer is yes and yes. It’s not the chicken or the egg; it is both.
We see in the literature that individuals who have the risk factors for the development of GI complaints, particularly functional GI issues – we can talk about what that means – are temperamentally more vulnerable to the development of an eating disorder. That was the piece that, oh my gosh, really hooked me in.
When you look at this intersection between particularly these functional GI complaints and eating disorders, and the physiology that is shared, what you look at that is common to that overlap are the temperamental traits, the psychological comorbidity – and what I mean by that are things like depression and anxiety. That is really the common thread.
When you look at the data, it is just astounding. When you see the prevalence rates of people with eating disorders who also have a GI diagnosis, in some studies it’s as high as 98%. That was the piece that I was like, we have got to be talking about this.
Chris Sandel: With that piece where the GI issues predate the eating disorder – because I guess in my mind, it’s very easy to look at, taking anorexia or restriction as an example, if you were in a situation where calories are being brought down, there’s less resources going to all of the different systems within the body, it’s then not that surprising that you would have digestive issues because there’s just not the same energy to be able to run your digestive system. But what you’re saying is a lot of the time that predates them then having the eating disorder.
Marci Evans: Yes. Of course, not always. We see both. But this is why when I do my clinical assessments, I always ask my clients about either histories – and if they’re discussing or talking about GI complaints, I’m asking about it from a developmental perspective and looking at family histories. If we think about it, it makes perfect sense that we have a child who is maybe temperamentally naturally quite anxious or a worrier, often tummy aches and anxious stomach can go in tandem with that.
Individuals who have digestive issues – oh my gosh, it’s so painful and it’s so intrusive and it can really impact quality of life. I think naturally, and understandably, there’s a desire to fix those symptoms, and the fastest conclusion that is often drawn is “it’s caused by what I’m eating, so I’m going to try taking this out or I’m going to try taking this out.”
If you take someone who is a very good rule-follower or very perfectionistic, they’re going to be very, very good at taking those foods out. It can be a bit of a spiraling into that rabbit hole, where you have temperamentally someone who’s maybe very anxious, very perfectionistic, perhaps more on the rigid side, a little bit more of a black-and-white thinker, coupled with complaints of having an upset stomach. They begin taking food out, and if they have that genetic vulnerability for an eating disorder, it’s a bit like a perfect storm. It really can set someone up.
In fact, I didn’t know this – I had been in the field of eating disorders for a number of years, attended countless conferences, and I had never heard anyone give a talk naming a primary risk factor for the future development of an eating disorder as early childhood eating and GI problems. I stumbled, in my literature search, on this article that listed the top common risk factors looking at risks for development of eating disorder, and one of the first risk factors named was early childhood eating and GI problems. I thought, oh my gosh, why aren’t we talking about this? How do we get the word out that these are kids who are going to be very vulnerable to the development of an eating disorder longer down the line?
And, as you mentioned, it can happen in the flip. Someone could stumble into an eating disorder, and because that naturally does damage the digestive organs and the digestive process, you can end up with GI complaints in that direction as well.
Chris Sandel: It’s interesting with the vulnerability piece, where this is a primary vulnerability to ending up with an eating disorder.
My worry now, given the climate that we live in and just this hyper-focus on diet and health and the way that these ideas are disseminated through social media – this just makes it so much more likely that if someone has digestive issues early on, they’re going to start to try and follow a ketogenic diet or go carnivore or whatever it may be that then leads them down that path, probably more than would’ve happened in the ’70s or ’80s because it just wasn’t so front-of-mind in the way that diet is these days.
Marci Evans: Yeah, absolutely. Dieting and diet culture is this shapeshifter, and now it’s presented in the form of having this halo effect and framed in this very positive way, that it is unconditionally a “good” thing to be removing certain things from your diet, and it is not without risk. I am so appreciative of my digestive health colleagues who are really getting this.
I’m not sure if you’ve ever followed the work of Kate Scarlata. She’s fairly known here in the U.S. She is a digestive health dietitian and she has done a remarkable amount of work around IBS and the FODMAP diet – and she does so, so responsibly. At this big conference I just mentioned, she gave a talk and talked about the risks of elimination diets and being overly rigid and taking things out.
My messaging is that that is the approach of last resort. We know to have a healthy gut, we want to have the diversity of food and how important that is physiologically, but also psychologically. My message with the training, and as I’ve had opportunities to speak on this topic, is that we have so many tools in the toolbox when it comes to supporting digestive health, and altering nutrition and taking foods out is one tool and should be used very, very carefully.
It’s not to say that it isn’t ever important for people with food allergies or food intolerances. Sometimes that is incredibly critical, and I believe that. And I think it is way overused. Way, way, way overused, and in the hands of the public, is taken very liberally. It’s jumping to “food is the culprit,” and large food groups are taken out. It creates so many problems – sometimes full-blown eating disorders and sometimes not. But it certainly creates problems.
Chris Sandel: She is a new name to me, so I’m going to check her out and then see if I can get her on the podcast and have a conversation about it. Because yeah, that sounds super interesting.
Marci Evans: She’s incredibly skilled, and she knows the science like nobody’s business. She would never call herself an eating disorder specialist, but we’ve had such a wonderful relationship over the years.
We actually co-authored an article in a U.S. dietetics magazine, really with that sentiment of being so, so careful about food restriction and food elimination. She has such a sensitivity to that, and I’ve been so appreciative of her because she has a very, very wide reach and is reaching other professionals who don’t work in the realm of eating disorders. Naturally, eating disorder clinicians are very, very careful about food restriction. So she has done such a great job of communicating that message to other people.
00:45:55
Chris Sandel: One of the terms you mentioned before in passing was “functional GI disorders.” What do you mean by the term “functional GI disorder”?
Marci Evans: Functional GI disorders are incredibly common. The distinction of a functional disorder is that there are symptoms or diagnoses that are a result of essentially poor communication between your head brain and what’s happening in your digestive tract. I think of it as a communication issue rather than a physiological issue.
With Celiac disease, we can actually look at the inside of the intestines, look at the villi, and see, wow, there has been actual physical damage to the structure of the intestines. But that’s actually not the case with these functional gut disorders. You can’t look inside someone’s GI tract and see that damage has been done. It’s, again, an issue more of a function and communication.
These are actually disorders that people are very familiar with. It has to do with reflux, it has to do with just general bloating, constipation, diarrhea, this nebulous stomach pain. It falls into the category, often, of people feeling like “My doctor tells me nothing is wrong, but I know there’s something wrong. My stomach isn’t working right.” IBS falls under this category. It’s often these symptoms that feel very hard for people to live with because there isn’t, often, a clear diagnosis.
Chris Sandel: What would be the way of dealing with something that’s a functional GI disorder versus something that is more like Celiac disease?
Marci Evans: Of course, it’s going to depend upon diagnosis, but in my experience working with GI issues, for individuals where there is say a diagnosis like Celiac disease – or say Crohn’s disease falls under this category, in that you have a really clear idea of what is wrong – but often even in the case of Crohn’s disease, the “what to do about it” can be fairly complicated. In the case of Celiac disease, it is so not fun, but the treatment, removing of gluten, is fairly straightforward.
In the case of these functional disorders, we have to be incredibly creative, and I find that we have to use lots of different tools. Sometimes it is looking at the pacing of meals and the timing of meals. Sometimes it’s looking at maybe the texture of foods that a person is eating. Sometimes we are looking at different medications that can provide relief. Other times we’re looking at managing stress and anxiety, and that is the piece that I think is often under-addressed and the piece that I like to highlight.
With these functional gut disorders, like I said, they’re an issue of communication between head and gut brain, which means it’s related to our nervous system. If we aren’t attending to the function of our nervous system, we are likely not going to have particularly great outcomes because we’re not addressing and paying attention to some of the underlying causes of the symptoms.
Chris Sandel: The thing with that is, as an eating disorder goes on and someone becomes fearful of eating or eating particular foods, and food then gets labeled as a threat, you then have basically the nocebo effect, where eating a particular food creates a symptom because of the psychological beliefs or thoughts around that food. You get stuck in that place where it’s like, how do I get through this and get to a place where I’m no longer fearful of that food when, in reality, every time I eat it I get genuine symptoms?
Marci Evans: Yes. It can be quite challenging. What I hope that I do as a clinician working with my clients is validate their real, lived experience in their body, and to really listen to what their experience is. I think often clients who suffer with these types of symptoms receive feedback from clinicians, particularly from the medical community where there’s a known eating disorder, “It’s all in your head. It’s a mental patient.” People are just so disregarded and poorly treated.
This is where I bring the science in, to say this is real and it’s alive in your body, and you are having physical symptoms, some of which are connected to your emotional experience and your thoughts related to eating. That might not be the whole entire picture, but we can appreciate that it’s part of the picture, and if we can work on this part, I will hope and expect that we will see some of these symptoms downregulate and be less troublesome for you.
So I try to really hold the whole picture. If someone is very clear – “Marci, every single time I have a glass of milk, here’s my experience” – okay, let’s work on that and let’s try a lactose-free milk. It’s not as if I’m totally opposed to working on shifting certain foods around. But I’m hoping to do that in tandem with lots of different approaches, and that we are expanding what is being eaten rather than contracting and restricting. I have found that my clients are often very receptive, especially as we’re in this open dialogue with one another.
Often where I try to begin with my clients, as much as possible, is some of the low-hanging fruit of the eating disorder symptoms which are guaranteed to cause GI distress. If that is eating large volumes of “safe” foods, like someone’s eating a handful of apples for their afternoon snack or eating lots of raw kale, that’s going to be rough on anyone’s digestive system. Or maybe they’re consuming a lot of sugar alcohols, trying to avoid calories, so they’re eating a lot of diet foods or chewing a lot of gum or drinking a lot of beverages with artificial sweeteners.
I provide that education that all of those sugar alcohols are going to cause a lot of bloating, so can we work on decreasing the eating disorder behaviors that will support recovery of the eating disorder, but also recovery of the digestive complaints? Often people are very on board with that. Or going long stretches of time without eating. That is so disruptive to normal GI functioning and the rhythm of the gut and how it likes to move things along in a rhythmic fashion.
So I find that when I bring in a lot of empathy, a really open listening ear, along with some science and along with some things that I think will give us a big bang for the buck, we can start chipping in there.
Chris Sandel: I would agree with you on that. They are the things where you see a pretty quick turnaround. With eating disorders, a lot of things take a long time and you’ve got to persevere and all that, but I would say getting someone to decrease their vegetable intake when they’re eating plates of vegetables every night – by doing that, within a short space of time – I’m talking a couple of days, a week – people really notice a difference.
Marci Evans: Yes. And like you said, you highlighted so well, it’s not that that’s easy for someone who’s in the throes of an eating disorder. It can feel psychologically very complicated and can take time. When they notice that they can start to feel better, that can really create a positive feedback loop.
I had a client who I worked with for many years, and she had numerous GI complaints. No clear diagnosable GI condition. She had forward movement in recovery and relapses, and I can tell you that when she was able to nourish herself consistently, eat in a balanced way, not abuse Diet Coke, take her medications responsibly, most of her symptoms improved.
Now, I want to appreciate that you will have listeners who say, “That’s not my experience.” Of course that’s unfortunately not going to be the experience for everyone. But for individuals in that space of eating disorder and digestive health that are saying “what are the things that I can work on that are going to support me in both of these areas?”, it can be very, very helpful without getting too preoccupied with “what do I need to be taking out?”
Chris Sandel: Yeah I feel like so much of recovery is a little bit of blind faith, like “this will get better in time,” whereas with this one there is just more of an “I am noticing that my bloating’s not as bad as it used to be” or “I notice my stools have got better in a week.”
Marci Evans: Yeah. One of the things – and I’m not sure how much you want to discuss this today – where I think we as practitioners can feel so insufficient is that there are still a lot of unanswered questions. We’re just barely being able to look at research that is done on folks in recovery from eating disorders and the consequences of altering the gut microbiome.
We do know – this for me really points to the dilemma that I’m often in with my clients, where we’re doing all the work that we can do, and we have these persistent GI symptoms. It breaks my heart, and it feels so frustrating to me. I do think that we are going to learn more over the coming decades about the role of the gut microbiome, because we do know, particularly food restriction in the context of an eating disorder, that it does disrupt a healthy microbiome. You see a decrease in the amount of bacteria as well as a decrease in diversity.
One of the mind-blowing pieces of research that I stumbled upon, which you learned about in the training – maybe you knew about previously – is that individuals who are nutritionally in a better place through eating disorders treatment, their gut microbiome more closely resembles individuals with functional gut disorders. So we know that at a very basic level, there is healing that remains even after symptoms are improved. I think there’s a lot that we need to learn about how we fully heal the gut microbiome, and will that produce improved symptoms from a GI perspective? I’m hopeful there. I’m optimistic.
Chris Sandel: And then how do you talk about that where it doesn’t become diet-y. So much of the chat around microbiome is talked about “and this is why you need to do paleo” or “this is why you need to cut all these foods out of your diet.” How you can then take what comes out of that and do it in a way that is constructive to someone who’s recovered from an eating disorder.
Marci Evans: That’s absolutely right. We can quickly go down a line of thinking that’s unproductive. From my standpoint, in conversations that I have with my clients, there is so much that we don’t understand, and quickly applying early-stage research to real life is a particularly precarious thing to do, particularly when we’re also treating an eating disorder.
I just saw a headline in the news that said something to the effect of “too much prebiotics are actually causing more problems.” We’re very quick to take a nutritional science headline and run with it, and that’s where we lean into – and one of my passion areas is when we’re looking at an eating disorder plus a medical diagnosis, we’re thinking very big picture around what is going to support both. We ride that together, as clinician and client.
Often what is the case is something that is going to be much more moderate than any type of eating pattern that is proposed in an extreme way, whether it’s intermittent fasting or eliminating massive food groups. That, physiologically in the long term, we don’t have great evidence for, and also we know in the short term, it’s psychologically pretty problematic – and non-sustainable for most people, not just people with eating disorders.
Chris Sandel: With all of those things, even if it turns out to be true that intermittent fasting is helpful for a subset of the population, I’ve always got to look at the upside/downside of something. Okay, potentially this could be useful for someone, but the downside is it could potentially drive someone to an eating disorder. No matter how amazing it may be on paper, let’s think about this realistically. What is the potential harm that this could cause?
Marci Evans: Yes, that is so well-said. I have had variations of that exact conversation – I had a really wonderful client come in whose husband has a diagnosis of a really devastating genetic disease, Huntington’s disease, and she was desperately looking at the literature on intermittent fasting and the potential impact that this could have on her husband’s quality of life. My compassion – oh my gosh, my heart broke.
I shared with her, it is this cost-benefit. Right now, I don’t know that we have any useful long-term data, and we have to think very practically about what that science, how it looks under a microscope versus how it looks in a person’s day-to-day quality of life. That’s something to know, that that is just valid, if not more valid, than the conclusions drawn in that scientific paper.
01:00:30
Chris Sandel: Totally. One of the things I really liked about the training was the research – I didn’t know about this – around hypnosis and digestive issues. Do you want to talk a little about this? Because this was pretty astounding.
Marci Evans: Yes, thank you so much for bringing that up. I will say that it was Lauren sharing the research on gut-directed hypnotherapy – my jaw dropped, and I said, “Lauren, we have to be sharing this information with more people,” because I did not know this.
The data that she shared with me was on some research studies that compared efficacy on GI symptoms looking at folks who were given low FODMAP intervention – do we want to talk about what FODMAP is or what that means?
Chris Sandel: Yeah, you can give a quick summary of that.
Marci Evans: It stands for Fermentable Oligo-, Di-, Monosaccharides And Polyols. It’s a classification or groups of carbohydrates that have become really notorious for creating GI symptoms, the nebulous GI symptoms like bloating and gas and stomach pain.
The research that Lauren pointed me to demonstrated that looking at a person going on a FODMAP diet versus a person or group of people receiving gut-directed hypnotherapy, the gut-directed hypnotherapy was actually just as efficacious at improving GI symptoms compared to the FODMAP diet. The FODMAP diet, we should say, is extremely difficult to follow. It is highly restrictive. It’s not a protocol that I ever use for my clients because it is so restrictive.
So it was fascinating to see that looking at the GI symptoms, the abdominal pain, the bloating, the gas, the nausea, looking at satisfaction of stool consistency – which is something that you look at in GI research – we had similar improvements. However, we saw an increase in improvement in anxiety and depression with the group that participated in the gut-directed hypnotherapy that we didn’t see in the FODMAP diet group. So there was an additional benefit that I don’t know that the researchers were anticipating for utilizing the gut-directed hypnotherapy. That was pretty exciting.
Chris Sandel: Since doing this and finding out about it, this has been a recommendation I’ve made with many clients, and there’s probably only one that comes to mind where they didn’t feel a major benefit from this. Everyone else was like, “When I do the hypnosis on a daily basis or on a regular basis, I notice that my symptoms are better. I’m passing better stools.” It tracks that things are better when they keep doing this.
Marci Evans: Yes. That’s really interesting, hearing your experience anecdotally with your clients. One thing that I will say, often one of the top questions I get from people who have heard me speak on the topic or who have taken my course is, “Where do I get this hypnosis?” Because it’s not necessarily “easy” to come by.
Actually, as a result of reading this research, I participated in a Level 1 training here in the Boston area on gut-directed hypnotherapy, so it’s something I do have a bit of training in. I absolutely would not consider myself an expert.
But what I would say is even if you can’t get a hold of gut-directed hypnotherapy recordings or protocols or clinicians – there are clinicians who are certified in this – even if you’re not able to find someone in your area or to do it remotely, even just participating in guided meditation that is focused on helping you to move into more of a relaxed space is a fantastic start. We are realizing and learning more and more that through meditation and hypnotherapy, we are able to connect that gut-brain and that head-brain, and that we can learn how to downregulate the intensity of what is happening in our guts.
Individuals who tend to have more physical symptoms in their gut tend to be folks – I have my hand raised – who lean in the direction of we feel things a lot. We are highly sensing people. We tend to move towards anxiety or stress very quickly. We tend to I think run on a little bit more cortisol and adrenaline. So I think it’s about teaching our bodies how to settle down, how to relax a little bit, how to downregulate.
So not to be discouraged if you’re not able to move into a more formalized treatment, because it’s certainly not accessible to everyone.
Chris Sandel: Yeah. I’m blanking on the name of the app that I use with people. Someone from Australia has put it together. I’ll put it in the show notes.
Marci Evans: Please put it in the show notes. I don’t know that I know about that resource. Thank you.
Chris Sandel: Cool. Yeah, I will definitely share that. Let’s shift focus now and talk about the second area, which is body image. I think you alluded to this earlier on, but was there any training on this whatsoever as part of your dietetics training?
Marci Evans: Not at all. Not even the slightest. I don’t even know that I ever once heard the term “body image” ever used in my undergraduate. Certainly, I heard it a bit in my graduate work because it was a specialization in eating disorders, but I did not receive any training on how to work with negative body image. It was like, “yes, this is a diagnostic feature of an eating disorder,” but in terms of what you do about it? Absolutely nothing.
01:06:55
Chris Sandel: That part, the ‘what you can do about it’, is something I want to explore. I guess to start with, do you have a working definition for what body image is or how it’s defined in the literature? Is there an agreed-upon definition?
Marci Evans: Oh my gosh, it’s as if I just handed you that question. I’m so glad you asked that question, because it is how I begin almost every one of my talks or workshops, and it is also how I begin with my clients.
I think it’s such an important question. What do we mean by body image? What it means to me may be very different than what it means to my client. Even using that as a place for exploration, as a way to start “body image work,” I think is so valuable. There are academic definitions. There’s a working definition that I keep in my own mind, and I think equally important is how the people that we work with, what it means to them.
I would say academically, a common definition of body image is a person’s perception – and we can talk about what that word means – of their physical self, and the thoughts and feelings that result from that perception. We can think of it as this interplay between thoughts about one’s body, feelings about one’s body, perceptions or inner states or sensory experiences of one’s body, and how that causes them to act in the world, feel in the world. That’s one way to think of it.
A more simplistic way to think of it, how I often think of it in my own mind, is the subjective experience or picture of one’s own body. I think perception and subjectivity are very important words because it speaks to the body image experience, which is not concrete or objective or fixed. It is highly malleable. It’s changing. It waxes, it wanes. Those are some of the ways to think about what we mean when we say body image.
I’d be curious to know: do you have a working definition in your own mind, or what it means for you?
Chris Sandel: That’s a good question. I think it would be – it is kind of a fuzzy idea. I would say there is that part where it is much more, as you say, about perception as opposed to reality. Whenever I’m talking with someone, at least from my side of things, I’m trying to track how much their perception tracks on to reality. But yeah, in terms of a definition, I would probably struggle to come up with one, or it would be one of those things I would ruminate on and then muddle my way through if I was trying to write one out.
Marci Evans: Yeah. I think that’s wonderful that you’re even able to identify that. I encourage all clinicians who are possibly working on body image with their clients or are interested in doing body image work with their clients to start there and say, “Gosh, what do I mean or what do I think that means? Or what does it mean to me?” Get, I think, less bogged down in what is the correct definition, and just connecting to the felt sense of it for yourself.
I have these very organic conversations with my clients, and how I might “define” it one day might be different than another time I’m talking about it with my clients. But I think reflecting on it and getting more clear in your own mind, “gosh, when I say body image, what do I even think I mean by that?” and to talk it through in an open way with the people you’re working with.
I’m teaching, as I mentioned, this graduate course on Nutrition Counseling for Eating Disorders, and just last week we had our lecture on body image. We gave our students an activity to pair up and write down the most exhaustive list they could possibly think about of all of the different factors that may inform a person’s experience of their body or their body image. We had a list – I regret I didn’t take a picture of it – I think that there were probably 50 to 60 things written on the board. Everything from medical diagnosis to social media messages to family culture. You can imagine, this exhaustive list.
I think it really represented so beautifully why we do stumble on body image and why we have such a hard time getting our arms around it, because it is actually this entity which encompasses so many things that we hold in our bodies, we hold about our bodies, we feel in our bodies, we think about our bodies. So I think that we can have a lot of compassion around the muddling through and feeling lost, because it’s filled with so many things that are so important, and also a lot of complexity.
Chris Sandel: Yeah. I think part of the reason why I struggle to answer is this isn’t a question that I directly ask clients. I’m definitely going to start doing it now that we’ve had this conversation. I mean, I talk a lot around body image and all of the different facets that come with it, but not as an overarching question of “what does body image mean to you?” that then has, as you say, those organic conversations where you have a slightly different working definition every time you have a conversation with someone.
Marci Evans: Yeah, very cool. I’ll be interested to hear how those conversations go for you.
01:12:55
Chris Sandel: As a clinician, then, how do you assess body image? Is there a checkbox thing that you go through? Are there specific questionnaires that you go through? Or is it more of an organic process?
Marci Evans: That’s a wonderful question. I’m cracking up over here. You can’t see me smiling. It’s as if you were moving through the slide deck of the presentation I gave on Sunday. [laughs] This is a wonderful question.
I gave a series of live body image workshops for clinicians with my wonderful colleague, Fiona Sutherland. In the process of the development of that workshop, I spent hours upon hours upon hours looking at the literature of body image assessments and looking at all of the tools that have been developed from a research standpoint through these validated measures of how we assess someone’s body image.
Several of those tools have actually been used in a book that’s available to anyone. It’s not a clinical book; it’s not a book that’s written for training clinicians. It’s a book called The Body Image Workbook by Thomas Cash. It’s been around for a number of years.
Chris Sandel: I have it sitting on my desk. I was just about to ask you about that, so it’s fine. [laughs]
Marci Evans: Yeah, you can spend some time with Thomas Cash’s book. He is, my gosh, almost the father of body image research. He’s been doing body image research for probably 30 years. The beginning of his book actually has a number of those assessment tools.
So there are lots of ways to assess for body image. Some of those tools I think are more useful than others, but I feel as a practitioner, that was a helpful way for me to get my start and build familiarity of how we can assess a person’s experience of their body.
But I would say that once I actually not only used Thomas Cash’s book, but went down the hole of reading the background of each of these assessment tools – I will save you the hours of doing that work and I will tell you, each of those assessment tools are incredibly flawed. They were developed many years ago with less thoughtfulness around weight bias, less thoughtfulness around cultural bias. So I don’t actually love any of those tools. Not to say that they are completely useless; like I said, I think it can be a really useful place to start to get to know this field a little bit more and get a little bit more comfortable.
But now that I’ve been doing body image work for a while, I don’t personally use any of those tools anymore when I’m working with my clients. I have moved into a much more, what feels for me, organic process of talking with my clients. I think I feel less of a pressure of getting the correct checkbox or asking the exact right question. But I do think I needed to go through a little bit of that learning process. One of the useful things with the assessment tools is it gives you a sense of the multiple dimensions that body image lives in and helps a clinician understand all of the different facets of how body image can be explored and assessed.
But I think I have moved into a more comfortable place myself in assessing for body image. I actually created a cheat sheet. If you think it would be useful, I would be happy to give you a link on my website where I have this cheat sheet, where anybody can download it – doesn’t matter if you’re a practitioner or not – and a couple of research articles. I can provide you with that link.
Chris Sandel: Yeah, that would be great. I probably discovered the Thomas Cash book in the last 6 to 9 months, and I use it with some clients and not others. I guess the thing that I find helpful with the assessments for clients is for them to understand what facets or what parts of body image are a struggle and what aren’t, because it then can give certain language or it can give a sharpening of or an awareness of where I need to put my focus.
Because sometimes body image work can be talked about as this thick brush stroke of “oh, you’ve just got to do these 5 things and then you’re going to feel better about yourself.” By using those assessment tools, then you can see, “okay, now I understand why that thing for you wasn’t so much of a struggle, but you’re really having an issue with this thing over here.”
Marci Evans: That’s a great point. That’s a really, really great point. Because in the assessments there are so many questions to answer, it opens up our understanding together as we do the work of all of the different areas – and areas in which maybe they didn’t realize that there were strengths. That can feel good.
And then I think, like you said, it can give direction to where we’re going to go with this. A person might be able to look at the results of their assessment and say “I actually really would like to begin here. This place is very meaningful for me, and I’d like to begin on this part.” So it can be clarifying and it can be directing. I’m so appreciative of you sharing your experience. It’s great.
Chris Sandel: I think for me, a lot of the times, a lot of the work I do around this is find areas of cognitive dissonance where you’re like, “You say that this thing doesn’t bother you, but this other thing does. I want to understand how those two things can sit together, because I know that thing that you say doesn’t bother you, it bothers a lot of other clients. How are you able to just walk away from that and that not be a thing?” And then this thing that really does bother you, could you imagine it not bothering someone? Okay, so how do they manage to do that?”
Sort of use those two areas that are at odds with one another to get them to understand how they can make changes.
Marci Evans: That’s really interesting. That’s great. That sounds like really fruitful work.
01:19:30
Chris Sandel: I went through as part of looking at this course for doing the questions for today, and in one of the modules I know you spend time on looking at the importance of words and that words really matter. You alluded to that earlier when talking about maybe some of the problems with the Cash book or with the questionnaires as part of that in using the wrong language. Are you able to talk a little bit about what is covered as part of that module and why you think this is so important?
Marci Evans: Sure, I’m happy to. I try my best when I’m in conversation with my clients or when I’m on a podcast to be mindful of my language and the words that I use, because I think language not only has the direct meaning of a word, but also the connotation or associations that we have with those words – sometimes that we’re aware of consciously, and sometimes that we’re not even aware of. It lives in a below level of conscious type of place.
We live in a medical culture and in a social culture that speaks about bodies in ways that are incredibly problematic. I think that those experiences have impact on a person’s self-image and sense of their body. From a medical standpoint, words that are often used to describe higher weight bodies, such as “overweight” or “obese” are inherently pathologizing or inherently placing illness or assuming a problem based on a higher weight size.
I think it’s important, particularly for myself as someone who tries to support other people, to remedy some of that. If we say the body is overweight, that’s assuming a standardized assumption of there is a narrow set of weights that are acceptable, and erases the notion of body diversity and that we are actually meant to live in a society where we do have body diversity.
The normative idea is we are all meant to be squished together in this narrow range of BMIs – and there’s actually more and more literature coming out to challenge that, but that’s the prevailing narrative. The word “obese” assumes illness based on size, and we know that illness spans all body sizes and that, as human beings, none of us are going to be able to prevent any and all illness simply by managing the size of our bodies.
So those are things that I try to work on in training professionals, but also work on with my clients. Those are open dialogues and open conversations that I have the luxury of having, because I get to have long-term relationships with many of my clients.
Also, getting curious with them about ways in which their bodies have been spoken about by perhaps family members over time, and ways in which they’ve learned to speak about their own bodies in ways that are inherently judgmental or shaming. Learning to be able to speak about and be in relationship with our bodies in ways that are more neutral or more descriptive has its own way of being healing. Those are some of the thoughts that I have.
Chris Sandel: Sure. Do you notice, by having these conversations with clients and getting them to use different labels when talking about size or whatever, that that has been helpful for them to move past or get better with body image?
Marci Evans: Yes. I would say particularly for my clients who are in higher weight bodies. One of the things that it has helped them to do is shift essentially where the finger is pointed. For people particularly who are in higher weight bodies, the finger has always been pointed at their bodies as the problem.
It helps to shift and locate the problem outside of themselves and point the problem in the structures and in the systems and in the politics that live outside of us. I think for some people that can feel very liberating. Now, it doesn’t, of course, extinguish all negative body image. I don’t even think that’s the goal of body image work, necessarily. But it helps to shift the balance of “blame,” and I think that that can be, for some people, very healing.
01:23:55
Chris Sandel: I know we’re running out of time, so I just want to ask one more practical question that someone could take with them. Are there examples of body image interventions for eating disorder clients that you can give? I think some of these may be talked about as part of the course that you’ve got. Are there any that come to mind that you want to talk about?
Marci Evans: Sure, I’m more than happy to share a few ideas. I think before I do that, one thing that I will offer to your listeners to think about – and I hinted to this just a moment ago – from my vantage point, working on negative body image isn’t with the goal of always feeling positive regard towards your body or feeling positive about your appearance. That is impossible. It would be a goal that you would always feel that you’re failing at, another standard that can’t be met. We don’t want that.
I often compare it to the goal of going to therapy isn’t so that we only feel happiness and never feel sadness. I think about being in relationship to body image, and that’s one of the tools I try to help my clients build: being in relationship to your body image experience.
One of the practices that I teach is I encourage people to make a list. Think about, first, one of the best relationships that you have in your life, whether it’s a partner or a friend or a colleague that you feel is really representative of an incredibly strong, healthy relationship that’s very functional. Write down as many of the characteristics of that relationship as you can, and think about “I’m also in relationship to my body image. How do I begin to try to cultivate some of those same characteristics?”
Often people will say dependability or kindness or offering compassion. What are the things that, right now, you are able to do or not able to do, that helps to build some of those qualities? That can be a useful place to begin. It’s not that you don’t ever have bumps in those relationships or you don’t ever have disagreements or times in which you’re incredibly annoyed or disappointed or frustrated. That’s a natural part of any relationship. But it also has some of these other key characteristics that make it a lifelong, hopefully thriving, functional relationship.
So that’s one piece that I would offer, to begin to maybe conceptualize a relationship to one’s body image.
I am a believer that perhaps the most important skill that a person can develop in trying to heal their relationship with their body image is cultivating the skill of self-compassion. That is for a couple of reasons. Self-compassion, in the literature, is actually correlated with individuals who have a more positive body image, so we know there’s something there in that relationship.
Self-compassion gives us the capacity to be able to build a little bit of insulation between ourselves and what lives outside of us because we know what lives outside of us as it relates to body messaging is incredibly harmful and toxic. It also really increases our capacity to move towards positive and healing change, and we also know that it’s correlated to improved psychological and emotional wellbeing.
So fundamentally, it gives us a baseline to build towards engaging with ourselves and our experience of our body in a way that is truly healing, and I believe empowering. So that’s actually a place that I guide myself to, as well as practitioners and individuals. Even going to – you can google – I think it’s https://self-compassion.org.
Chris Sandel: Is that Kristin Neff’s site?
Marci Evans: Yes, Kristin Neff’s website. Even just beginning there, and finding a way of relating to self-compassion that feels natural and that feels authentic. It’s not necessarily going to feel like the right fit if you just listen to maybe Kristin’s meditation. Maybe that doesn’t resonate for you. But find ways in which it can feel real, feel authentic, and that is I think a cornerstone of body image work.
Another piece that I would highlight to listeners, and to take very seriously, even though this isn’t new advice, is to diversify and get very, very selective about the media that you bring into your life. We are inundated – even in areas in which we don’t have the ability to choose – we are inundated with messages that are meant to leave us feeling badly about our appearance.
So we have to be proactive. We know in looking at the research related to positive body image that there are some core facets that are correlated with a more positive body image. One of those is having a broad conceptualization of what beauty is, so being able to broaden your definition, and what are ways in which you might find beauty in hidden places rather than this narrow version of beauty that is fed to us.
Those are some of the beginning key pieces that can help a person begin on their journey.
Chris Sandel: Nice. On the self-compassion end of things, Kristin Neff is someone who I would recommend, and then Tara Brach is the other one. They have slightly different tones to one another, so I’ll often recommend both of them, or if someone doesn’t get on with one of them, I’m like, “check out this other one.” Their messaging is not completely the same, but it covers a lot of the same stuff. They just seem to attack it slightly differently.
Marci Evans: I am so appreciative that you mentioned Tara Brach’s work. I was trying to be concise, but the pieces that I recommend are self-compassion practice and mindfulness-based practice, and I know so many people do not love the word “mindfulness.” I will tell you, I had a long process myself in getting onboard with even the concept of mindfulness, and for many years found it really obnoxious.
But I will tell you that Tara Brach’s book Radical Self-Acceptance – I believe that’s the title.
Chris Sandel: Yeah, I’m pretty sure that’s the one.
Marci Evans: I can spot check it and make sure we get the accurate title for your show notes. It was truly transformative for me in body image counseling. Now, it’s not a perfect book. There are ways that she actually writes about food that I find problematic.
Chris Sandel: I think the same thing about Kristin Neff as well.
Marci Evans: Yeah, I fully agree. There are parts woven throughout Kristin Neff’s book on self-compassion that I cringed. I was like, oh no! We have these wonderful, wise authors and thought leaders, and they are really missing it when it comes to food and weight.
But if you are able to take the pieces in there that work for you – like you said, the whole book isn’t going to resonate, but I think that there are pieces in there that apply so beautifully to body image work, particularly Tara Brach’s work on being able to tolerate and being with, in a compassionate way, things that are inherently painful. Because there are things that are inherently painful about having a body. It’s about learning to live in relationship to those things with greater self-compassion and skill that I think is really key.
Chris Sandel: Yeah. Marci, this has been wonderful. We’ve covered a lot. I’ve made reference a couple of times to your courses, and I highly recommend that people go check them out. Where do you want me to be directing people? Where should they go to find out more information about you?
Marci Evans: Oh, thank you. On social media, I’m @MarciRD everywhere. My website is www.marcird.com, and I think that’s probably the easiest place for folks to go, individuals or clinicians. My trainings are designed for clinicians, but I’ve actually had individuals take them for themselves, especially people who haven’t had access to treatment, and let me know that they felt helpful. They were not designed to be treatment, but I found that interesting.
But you can learn about my trainings on my website, and that will direct you to a landing page. All of my trainings live on a Teachable website, but you can learn about them on my website.
I also will mention that if it’s of interest, I do have free resources, digitally on my website, a few resources that individuals can use. It’s in the dropdown menu as they click on “Clinician” or “Individual.” Some meditations and some tools that will hopefully be of use, both for the practitioner side as well as for folks who aren’t practitioners.
Chris Sandel: Perfect. I will put all of that in the show notes. Thank you so much for coming on the show. This was great.
Marci Evans: I really appreciate the invitation. This has been such a rich and wonderful conversation. It’s very meaningful to me, so thanks so much.
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