Episode 196: Chris talks with Josie Geller, PhD, about her research in the eating disorder field. They cover topics like predictors for success in recovery and predictors for relapse, the difference between collaborative and directive change, and the importance of self-compassion in recovery.
Josie is an Associate Professor in the Department of Psychiatry at the University of British Columbia and the Director of Research in the Eating Disorders Program at St. Paul’s Hospital. The primary focus of her clinical research is patient-centered, collaborative care that promotes client autonomy, well-being and best outcomes. She is interested in client readiness and motivation, therapeutic alliance, and self-compassion. While Josie’s work has focused primarily on the assessment and treatment of individuals with eating disorders, her clinical and research interests have been applied to other populations, including HIV, substance use, and obesity. She is widely published and an internationally renowned speaker.
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Chris Sandel: Welcome to Episode 196 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/196.
Seven Health is currently taking on new clients, and there’s a handful of reasons that clients commonly come and see us. Hypothalamic amenorrhea is the first one, and this is the fancy name for not getting a period. This is often the result of undereating and over-exercising for what your body needs, and this is irrespective of your actual weight. It’s almost always coupled with body dissatisfaction and a fear of gaining weight.
We work with clients along the disordered eating and eating disorders spectrum. Sometimes clients wouldn’t think to use the term disordered eating to describe themselves and what’s going on, but they see they’re overly restrictive with their eating, they have fears around certain foods –whether that be bread or fat or carbs or processed foods – they feel compelled to exercise excessively, and/or they find themselves binging and feeling out of control around food.
Clients also wanting to move on from dieting would be another area. Clients have had years or even decades of dieting and are realizing it’s just not working, but they’re struggling to figure out how to do food without dieting. What should they eat? How do they listen to their body? What will happen with their weight? They’re confused and overwhelmed.
Then the final is body dissatisfaction and negative body image. Many clients experience feelings of body shame and hatred. They find themselves fixated on weight and determined to be a particular size and a particular shape and frustrated by what they see in the mirror. They may even avoid social events and opt out of photographs, or even put off going to appointments like seeing the doctor, as a result of negative body thoughts.
In all of these areas, we’re able to help, and we do this through a mix of understanding physiology and psychology, so understanding how to support the physical body and how it works, but also being compassionate and uncovering the whys behind clients’ behavior so we can figure out how they can change this.
If any of these areas are areas you want help with, 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 you can apply for a free initial chat. The address, again, is seven-health.com/help, and I’ll include that in the show notes as well.
Hey everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. Today I’m back with a guest interview, which I’m really excited about. But before I get started with it, I want to announce the winner for this week’s book giveaway. If you’re a regular listener, you already know about this change, but we recently created a Resources page on our website, which is at seven-health.com/resources, and we started giving away a book from this page with every new episode of the show.
This week’s winner is Rachel C. Thank you so much, Rachel, for your lovely review. It’s very much appreciated. We’ll be in contact to send you a book of your choosing.
This weekly podcast show is something that takes a lot f time and something we are very proud of, and we want more people to be hearing about it and listening to it and being a regular listener. Reviews help with this by increasing the visibility of the podcast and recommending it to listeners of other similar podcasts.
They can also help you to win a book, so if you want a chance to win a book, all you need to do is leave a review on iTunes, take a screenshot of it, and then send it over to info@seven-health.com, and then you’ll be permanently entered into the draw. We greatly appreciate everyone who has done this already, and if you haven’t, it would be really appreciated.
This week on the show, it’s a guest interview. My guest today is Josie Geller. Josie is an Associate Professor in the Department of Psychiatry at the University of British Columbia and the Director of Research in the eating disorder program at St Paul’s Hospital.
The primary focus of her clinical research is patient-centered collaborative care that promotes client autonomy, wellbeing, and best outcomes. She’s interested in client readiness and motivation, therapeutic alliance, and self-compassion. While Josie’s work has focused primarily on the assessment and treatment of individuals with eating disorders, her clinical and research interests have been applied to public populations, including HIV and substance use. She is widely published and an internationally renowned speaker.
I became aware of Josie’s work a couple of years ago. I think I made a comment on one of my podcasts, or maybe I asked for it in an email, for ideas from listeners of who I should be interviewing on the show. One of the regular listeners sent a number of names over, and Josie was one of them.
Up until this time, I wasn’t aware of Josie or her work, and she actually mentions at the end of the podcast that she isn’t on Instagram and other social media, and neither is St Paul’s Hospital, where she’s the Director of Research. So I went onto PubMed and started checking out her name and her articles, and there’s this long list of papers that she’s been involved in writing. Then I went and found all the originals of the papers so I could read them in full.
Interestingly for me, it was topics areas that I’m hugely fascinated by. My day-to-day work is as a practitioner, doing one-on-one work with clients, outside of this podcast and the writing and the usual aspects of running a business, is how I spend all my time. This is what Seven Health is about, and it’s what I’ve been doing for over a decade. So a big part of what I want to read about and learn about is how to become better at being a practitioner. Josie has a lot to say about this and a lot of research to back up what she has to say about it in the area of how you make practitioners or clinicians better at what they do. This was one of the big things that made me want to get her onto the show.
This has been a long time coming. I first reached out to Josie in late 2018, and we had lots of emails back and forth and struggled to make a time work. But finally, in February time of this year, we were able to make it happen and have that conversation.
As part of this podcast, we chat about Josie’s background and how she got into working in eating disorders, both as a clinician and as a researcher, and then we used many of her papers that she’s been involved in as a jumping-off point for the conversation. A lot of it focuses on how to be a better practitioner, which might sound like it’s only relevant to other practitioners, but this is relevant to anyone. If you’re working with someone or you’re thinking about working with someone, these are things that are useful to keep in mind.
We talk a lot about readiness and motivation and predictors for success in recovery and predictors for those that are likely to relapse versus those who aren’t. Compassion is one of the big components here, and we talk about the wonderful resource that is the Fears of Compassion scale created by Professor Paul Gilbert. Understanding why behavior is occurring and knowing what it’s doing for someone is another component of success.
This is a hugely important podcast for anyone in recovery or thinking about recovery, and this is also true for those who work in the field. I’m very much a work in progress and I’m constantly trying to get better, and I know that I’ve improved because of me reading the research of Josie Geller and then applying it in practice. I really love this conversation. Josie is incredibly kind and caring and just has this beautiful nature to her.
I will be back at the end of the episode for a couple of recommendations of things you can be checking out, but for now, let’s get on with the show. Here is my conversation with Josie Geller.
Hey, Josie. Welcome to Real Health Radio. Thanks for joining me on the show today.
Josie Geller: Thanks so much for having me, Chris.
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Chris Sandel: I’m a big fan of your work. I think I’ve read most of the papers that your name has been attached to when I search in PubMed. There’s really two things that have been reoccurring in the research that you’re involved in and the papers that I’ve read, and these two things are very much interconnected and feed off with one another.
One of them is a focus on clinicians and how clinicians can be better at what they do. I have many clinicians or practitioners who listen to this podcast, so we can direct some of the discussion towards them, but I also think for those in recovery or wanting to be in recovery, they can use this as a way of reflecting on treatment or as a way, when looking for help, some of the characteristics they can be searching for in someone they’re getting help from.
The second part I see in your research is looking at clients and their readiness and their ability to actually make change. Again, this is dependent on the clinician in terms of the environment that’s created and the dynamics of that relationship, but it can also be coming from the individual and things that can be assisting their readiness.
There’s obviously an overlap between those two, and they’re ideas that you’ve explored very extensively in your research, and I think listeners would be really helped by being able to hear it. But I also want this to be a proper conversation, so I’m happy to just see where it leads us. Don’t feel boxed in by any of that. Wherever it goes will be fine with me.
Josie Geller: Fantastic. That’s such a lovely summary of what I think my passion has been over the past 20 years or so of just being fascinated about the nature of relationships that promote change. What’s going on in the room between two individuals where there’s a sense that something good will come of this and that we’re working together on the same side, and a sense of agency and collaboration, and how different that feels when there’s a conversation that could be about the same topic, but there’s a real sense that we’re not really working together, that we don’t have the same idea about where we wish things to go, but it’s not quite on the table; it’s inhibiting perhaps both people of being fully authentic.
It’s a sense that I think clinicians can sometimes have in the pit of their stomach of impending doom that the things that we’ve discussed that would involve change are unlikely to happen after this conversation. My group has become really interested in trying to understand the difference between those two scenarios, one where there’s that great sense of collaboration and movement and understanding and authenticity, and what’s different when that’s not there and we can all get stuck.
Chris Sandel: Definitely. When I went through all the papers that I want to touch on as part of this, there was a lot of reflection, from my perspective, of just thinking about how I am with different clients and how I talk about things or how I phrase things. So I found it really helpful for me just as an exercise in how I can be better and what are the things I’m picking up as part of this research that I think I’m currently doing, and what are the things where I’m like “actually, I’m doing this thing that’s being outlined as something that’s maybe not so great for the client.”
Josie Geller: Yeah. One of the things that I really hope that anyone who’s listening today gets out of this is that I think we all find ourselves sometimes going down paths that we may not view as most helpful when we reflect back on it afterwards, and that seems to be part of the human condition. It’s so easy for us to go in directions that are not always completely what we consider to be most therapeutic, and it’s okay that those things happen.
What I think is really helpful is for us to have an opportunity to get clear on, what is our highest aspiration? What is the approach that we want to take? Not so much the actual words that we use, but overall, what is our objective of what we’re trying to accomplish? I find when we can keep that front and center, it’s possible to redirect ourselves, and that patients and friends and so on can be quite forgiving when we stop ourselves and say, “Oh, I think I just caught myself saying something that wasn’t quite along the lines of where I’d like to go. Can we press reset and move forward again?” That’s perfectly fine.
My sense is that when the overall stance and approach and philosophy is in place, it’s perfectly fine for us to have slip-ups, and it’s quite human and natural.
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Chris Sandel: I think maybe a good place for us to start with this is 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, that sort of thing.
Josie Geller: Sure. My background is in clinical psychology. I graduated about 25 years ago. I was really interested in eating disorders, in part because I had some experience with disordered eating when I was younger. The relationship that I had with the clinician that I saw was life-changing for me, and it made me want to do the same thing for other people.
When I first started to work in a clinical environment as a young practitioner, I remember noticing that so many of the people who were coming for treatment were there not necessarily because they had decided that this was something that they wished to do and that it was their aspiration to make changes to; it was very often a family member or a partner, or possibly a clinician or a therapist, that was pushing them into more intensive treatment.
That just became something that I was thinking a lot about and feeling like it had a significant impact on treatment, but wasn’t really being addressed.
I remember as a very young practitioner going to my first conference and hearing the keynote speaker, who was describing a highly funded clinical trial treatment for anorexia nervosa. The dropout rate from this trial – at the time, it was one of the first trials of cognitive behavior therapy, ad the dropout rate was 65%. The conclusion that the keynote speaker came to was that what they had worked out was – and this is a direct quote – “anorexics don’t want treatment.”
I remember being really shaken by that, first by do we care about the efficacy of a treatment that only retains 35% of the people who start the treatment, and second, is it fair or is it most helpful to pathologize the patients rather than to look at what’s really going on here, what is the role of the relationship of the clinicians, are we offering treatment that’s actually compelling to individuals who are coming for treatment?
I think that combination of my clinical judgment of seeing clients who were coming to our service here and often coming because they were trying to please somebody else, and this jarring conclusion that I saw from this really important talk at a conference about how we were framing treatment and what our outcomes were looking like, it made me really curious to see, are there some variables that we feel are important but up till now haven’t had a way to properly assess and evaluate and understand better?
That was when my career in readiness and motivation started. We thought, can we identify the ingredients of a conversation where we’re actually talking about what’s most of the crux of what’s happening for someone who’s first presenting for treatment? We’re not having an entire focus on symptoms, but we’re actually talking about how that person is experiencing what’s going on with their eating and giving them some space to talk about what, if anything, they actually want to do about it – without being concerned that they will be judged or that treatment will be withheld or that there will be some kind of negative outcome for them being fully honest.
That launched 10-15 years of understanding that we actually could operationalize readiness and motivation for change, and it turned out to be extremely clinically helpful in figuring out what sort of treatment people would be most likely to respond to.
Chris Sandel: There’s a lot there that I want to go back to. When you did graduate as a psychologist, was it then always working within eating disorders, or were there some other areas you started off in?
Josie Geller: I started working initially just with families and looking at some family dynamics, attributions that parents make about their kids and that sort of thing, but it became clear within a year or two that what I was really passionate about was working with people who had eating disorders. At that point, the supervisor that I had kindly said, “Look, I can see that’s really where your heart is at. I will supervise you in an eating disorders dissertation if that’s what you’d like to do.”
And that’s what I did. There was no turning back after that. It was cool in some ways because that wasn’t my supervisor’s area, so it really put the onus on me to explore what I was most excited about. My dissertation involved developing a measure of the extent to which women in particular base their self-worth on shape and weight.
I developed this scale called the Shape and Weight Based Self-Esteem Inventory, and it was cool because it involved drawing a circle where you divide a circle into pieces, and the pieces are all the different things that I base my self-worth on. There was a list that you could choose from. It might involve my relationships, my physical appearance, my personality, my performance at school or work. People would pick off from this list initially. What matters to how I feel about myself as a person? Not “do I like these things or dislike these things?”, but “how much do these parts of myself impact how I feel about myself as a person?”
So they would determine which ones matter, and then they would rank order them – which one matters the most? If something were to be affected in this area, say my relationship or my performance at school or my shape and weight, it would really impact how positively or negatively I was feeling. So people would rank order them, and then they would divide this circle into pieces so that the size of each piece reflects the importance of that part to their overall feelings of self-worth.
You ended up getting a diagram of what matters to yourself as a person, like a self-concept of what matters. What was really cool about the way we evaluated the shape and weight piece is we would take a protractor and stick it on the circles and you would get an angle. It could range anywhere from 0 degrees to 360 degrees.
Indeed, we had in some of my research studies some individuals with eating disorders who ended up saying the only thing that really matters to how I feel about myself is shape and weight. Nothing else impacts how I feel.” So they would get what we would call a SAWBS score – SAWBS stood for Shape and Weight Based Self-Esteem – of 360 degrees.
But we found that people who didn’t have eating disorders, women who weren’t struggling or suffering, the size of their shape and weight piece was about 60 degrees. That was the typical female.
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Chris Sandel: Then as a clinician, did you continue to use that as a way of talking about these things and getting a sense of where someone was at?
Josie Geller: Yes, we did. In fact, it turned out to be one of the factors that was most associated with improvements in readiness. When we started to learn that readiness was something that we could operationalize, that we could measure – and that happened early on when we developed this thing called the Readiness Motivation Interview – we learned that we could actually have conversations with patients where they could articulate the extent to which they were interested in making changes to different parts of their eating.
In addition to getting people to describe the extent to which they were in what we would call different stages of readiness – not wanting to make changes, actively working on change, just thinking about change – we would also ask them to make one more rating, which was if they were actively working on change, how much of that change were they doing for themselves versus for others? Possibly for a family member or for a doctor or a boyfriend or girlfriend, that kind of thing.
They would give us a rating, which was the extent to which they were making changes for internal reasons. That could range anywhere from 0% for me, I’m doing it completely for somebody else, to 100% for me. But more often it was something like maybe 70% for me and 30% for others.
That last rating, which we ended up calling the internality rating, once we started to use the scores from the Readiness Motivation Interview in our research studies, that was the best predictor of relapse after patients graduated from treatment, which we thought was quite remarkable.
What they were telling us at the time that they started treatment, the extent to which they said they were there for somebody else, to please somebody else, not because they had decided that they wanted to do it, that was the strongest, best – in fact, only – predictor of relapsing 6 months after they completed treatment. So they would do this interview, go through treatment. Then we would get in touch with them 6 months later and that would predict which ones had maintained the changes and which ones ended up having more eating disorder symptoms afterwards.
Chris Sandel: That is quite a finding.
Josie Geller: It was really exciting. Actually, the interview scores themselves that we got from the Readiness Motivation interview, it was the first time that we had any way of determining which individuals would benefit from treatment. Prior to that, we would basically take people who had the most severe eating disorder symptoms and throw them into the most intensive treatments and hope for the best.
What we found was here, as in centers all around the world, we did have some individuals who benefited from these intensive either inpatient treatments or residential treatments, but we also had high levels of individuals who actually turned us down, who didn’t even engage in the treatment. We also had high levels of individuals who would begin but not compete the treatment. And we had some people who would complete the treatment but experience less benefit.
What was amazing about the Readiness Motivation Interview was it was the first time that we had scores that would predict all of those things – who enrolled in treatment, who dropped out from treatment, how much their symptoms changed, and then, as I was saying earlier, that amazing finding that their baseline readiness scores would predict relapse 6 months after they completed treatment.
So it was really a game-changer for us. We realized that this variable that we weren’t even really addressing or talking about – it was like a fuzzy thing, readiness and motivation for change. Up until then, we’d been more interested, like everyone else, in assessing personality functioning and psychiatric symptoms and eating disorder symptoms, but this other variable, this ephemeral, “How do I really feel about change right now?”, where we got these scores only in the context of this interview, were much more informative than any other clinical variable that we had looked at up until then.
Chris Sandel: Just so I have a point of reference, at what point did you start working as a psychologist with eating disorders? What year was that?
Josie Geller: I guess I graduated in 1990 – I’m feeling very old now. [laughs] So I guess it would’ve been in the early ’90s. We started to do the work with the Readiness Motivation Interview in the late ’90s. We got our first grant I believe in 1999.
At the time, it was quite revolutionary and we really hadn’t been talking about it. I’m really pleased to say that that’s no longer the case in the field. I think it’s hard to go to an eating disorders conference and not hear discussion about readiness and have that fully acknowledged as something that needs to be on the table in what we look at and how we address treatment.
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Chris Sandel: Part of the reason for me asking to say when you started is just to get a sense of what was the landscape with eating disorders like at that time, in the mid-90s? What were the things that were really focused on? Just to get a sense of how things have changed.
Josie Geller: I think it really was a much more medical-based treatment. We were very focused on body mass index and making that number go up as quickly as possible. I’d venture to say that we still have some ways to go; there are still some programs that will use that as their benchmark, most important variable. But what the readiness research suggests, and what our long-term outcome studies suggest, is that it’s not how quickly we can make changes in body mass index. It’s what happens in the long run over time.
We can put people into inpatient units and make significant weight changes when they’re under certification or sectioned, I think as you would say, but really what matters is what happens after they leave treatment. What we’ve found is that when the goals are coming from the clinical team and the patient doesn’t feel like they participated or like those are goals that are meaningful and important to them, it’s unlikely that the long-term outcome is going to be positive.
Chris Sandel: This is definitely what I’ve experienced when I’m working with clients. I’m in a lucky position in terms of the people that are working with me are self-selecting to come and get the help, so there is already a level of readiness. Sure, there’s going to be ambivalence and there’s going to be struggles and there’s going to be things that they are ready for and things that they aren’t, but definitely they’re further along on that spectrum.
I have conversations with them and they’ve been struggling for 5 years, 10 years, 20 years. They’ve had multiple stays in inpatient facilities, and it didn’t’ really matter that they were able to “weight restore” because they then got out, and the real other work around the deeper psychological components to this just weren’t dealt with. As you say, it’s like, “I went there because that’s where my mom wanted me to go” or “because my boyfriend was really worried about me” or whatever. It was not coming from a place of “I really need to and want to get this sorted out and figured out for me.”
Josie Geller: Yes. It seems there’s a decision that needs to get made at some point in the individual that “although my eating disorder has some functions” – and in the beginning they may not even be able to articulate what those functions are, and that’s one of the important components of recovery, starting out by understanding – I’ll often end up saying something like, I’ve never met someone who has an issue with eating that there isn’t a really good reason for that to be there, and it would be really unfair to ask them to get rid of it unless they’ve figured out, “What is the function, and is there some other way that I can have those needs met?”
That’s one of the ways that we’ll often work with people. We make sure we start with a really helpful or really in-depth functional analysis of how this thing came into the person’s life. And until they’ve made the decision that they believe that their life will be better without it or that the needs they have can best be met through some other form, then it’s unlikely that pushing change on them is going to be helpful.
Chris Sandel: I describe it in a very similar way. My phrase is “people keep their problems for a reason.”
Josie Geller: That’s right, exactly.
Chris Sandel: It is doing something really useful for that person, and we need to figure that out so that they can either find an alternative way of meeting that same need that is not detrimental, or what do we need to change so that need is now no longer important in your life?
Josie Geller: Exactly, yeah. Once we worked out that readiness had such a strong – really, there’s no variable in the field that has had a more consistent, predictive utility in looking at who benefits from treatment than readiness.
Once we figured out that readiness was so important, it led to all kinds of programmatic changes here in the service that I work. Rather than us be pushing people into treatment, we were actually having them make their decision before going in that this is something that they really wanted, and give them some preparatory treatment options where they could receive support and, on their own terms, in their own way, start to do that functional analysis and come to that decision for themselves.
So rather than us pushing them into treatment, the dynamics of the program switched where they would now be essentially convincing us that treatment was going to be beneficial to them. They were sort of eating their way into treatment or talking their way into treatment, which was really the opposite of how it was before.
Chris Sandel: I’m just thinking from studying motivational interviewing, that’s very much that approach. It’s getting the client to identify change within themselves, and then you noticing that change talk.
Josie Geller: Exactly. One of the ways that we were able to do that is we collected all of this data that showed that scores on the Readiness Motivation Interview were predicting outcomes; we then did a couple of studies where we just looked at patients whose readiness significantly improved over a 4-month period. We took that subgroup of patients – they weren’t necessarily in treatment. They could be in treatment or not in treatment. Sometimes they were just on our waitlist. But patients whose readiness significantly improved. We then looked at other factors that were associated with improvements in readiness.
Then when we identified what those factors were, we developed this super simple, five session outpatient therapy where each session was focused on addressing a factor that was associated with improvements in readiness. We called it a preparatory treatment. It was kind of like motivational interviewing in a very brief, five session delivery model.
The purpose was not to even address making changes to the eating disorder, but was just to address the factors that were associated with improvements. We offered that to patients over a period of time and did a little clinical trial of this thing called readiness motivation therapy, and what we found is that it did indeed lead to significant improvements in readiness, particularly in those who were highly ambivalent about change.
What was cool about it was it really had nothing to do with eating disorders. It had to do with understanding the function of the eating disorder – that was actually one of the things that was associated with improvements in readiness; the more insight they had about particularly how having an eating disorder was helping them to avoid something painful – to avoid either difficult emotional experiences or possibly taking on some responsibilities that they didn’t feel prepared for, but somehow it helped them to avoid something – the more insight they had about that was associated with improvements in readiness.
We had one session that was focused on really digging down deep to all the ways that eating or not eating has been helpful for them and really getting into it, and not stopping at the superficial – what we would call the “canned response.” Sometimes people will have one thing that they say, like, “Well, I just want to look like the women in the magazines” or that kind of thing.
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We do this technique that we call draining technique. It’s actually probably one of the things that I do clinically most often, even to this day, in my sessions. The simplest thing is to use words and body language that convey that I get what you’re saying – for instance, if we’re asking about how the eating disorder or how dietary restriction has been helpful, they might say, “It helps me because I like weight loss or I like maintaining a low weight.” We might ask, “What’s helpful about that?” They might say, “I feel better about myself when my weight is low.” We might ask, “Can you tell me more about that?” or “How does it help you feel better?”
They would say lots of different things. In the beginning, it might be things that they’ve heard themselves say before. But if we continue draining and saying, “Okay, I can hear that one of the ways that it’s helpful is you feel like you get more approval, perhaps from the environment, or attention from the opposite sex. Are there any other ways in which it’s been helpful for you?”, if we just continue to ask that question, they might say, “It helps me to have something to focus on. I like having my time occupied with exercise,” and so on.
We continue to drain, and very often at the end of the drain, maybe the last thing that they say or the second to last thing might actually be something new that they’ve never talked about before or never articulated before, like, “It helps me to avoid some painful feelings about myself or about some experiences that I’ve had.” That’s when we get to the really important part. We’re now talking about something that hasn’t been addressed before, and there’s almost an immediate shift, like, “Okay, now we know what we’re dealing with.”
In the readiness motivation therapy, we have one session that’s just dedicated to going as deeply as possible in all of the different functions that the eating disorder may be serving as a way of gaining more insight into what would need to take place to make changes, and is that something that’s desirable where they’re at right now?
There were a couple of other sessions that were dedicated to other factors that were associated with improvements in readiness, one of them being higher values. In that session, we do this – it’s kind of a morbid exercise, but we would ask people, “If you were on your deathbed, looking back on your life, what do you think would be the experiences that you would feel were most important, most meaningful, most valuable to you?”
I’ve done that exercise I don’t know how many times; no one has ever said “That I had a low number on the scale when I weighed myself.” This is when people talk about relationships and love and experiences that are connecting and joyful and connected with nature or doing things that they’re passionate about. That session I think just helps to highlight what they wish for, and is having the eating disorder helping them to get closer or further away from those experiences? It’s those kinds of things.
What we find is just doing a few sessions that are not even addressing the eating disorder leads to significant improvements in readiness, and in some cases, improvements in eating disorder symptoms, even though that wasn’t what we set out to do.
So that’s how learning more about readiness changed our service because we’re not pushing people into treatment; instead, we’re helping them decide if and when they want treatment. It led to significant reductions in our dropout rates and to our outcomes looking much stronger than they had previously.
Chris Sandel: The draining question I think was great in the way that you just keep going and going and going. I know I’ve done the 5 Why’s where you just keep drilling down and drilling down, but it seems like you’ve taken that to another level where you’re asking all the questions around pretty much all of these different topics. You just keep going.
Josie Geller: Exactly.
Chris Sandel: That’s a really cool technique.
Josie Geller: If there are any clinicians who are listening, when I’m giving workshops, I’ll often suggest just experiment with it. Go forth and drain. There’s an incredible shift in energy in the room when we get to the bottom of the drain and I’m saying, “Anything else? Anything else? Anything else?”, using words and body language and validation to reflect “I understand what you just said and I’m curious to know all the different parts about what’s going on for you and the function that this has served.” Or we could be draining about any number of topics.
But at the end of a drain, when we say, “Is there anything else?” and the patient says, finally, “Nope, I think that’s it,” there’s a shift in energy in the room. Very often, without even being prompted, the patient might start to say things like, “You know, I could think of one small thing that I could do to start moving in a direction of change” without even having to prompt them.
There’s something that’s so therapeutic about someone else having the courage and willingness to sit with them, with all of the reasons that this thing has been in their life, and fully take on and hold that space with them, that movement after that somehow becomes much different and easier. It’s quite a remarkable process.
I love it sometimes when people in my life will drain me, or I have fellow clinicians who might come and say, “I had a terrible session. Can you just drain me for a few minutes?” There’s something that feels so good about someone taking the time to just be with us and fully put everything on the table before getting into problem-solving.
Chris Sandel: Yeah, the problem-solving – so much of life, you’re waiting for someone to give you enough information so that you can jump in and say, “Hey, this is what you should do.” So when you have someone who’s just sat with you and asked, “Can I have more information? Tell me more about that” and then is able to just sit there and wait – that’s definitely one of the skills that I’ve learnt.
It’s still a thing that I need to get better at, just being able to sit and just wait and not have to be the one that is always moving things and pushing things forward. By being able to sit and wait, the client can then do that, and it’s helpful. It’s not even about creating awkwardness. It’s about if you just create that space and you allow the person to be able to think and feel, it’s amazing what comes out of that.
Josie Geller: Yeah. I think it’s human nature for us to see suffering and to want to get in there and fix it and solve it. I also think that it’s human nature to feel, when someone’s trying to solve our problem without a full understanding, that they’re not really helpful to us.
I think we’ve all experienced when we move into problem-solving and the patient will say, “That’s all very fine, yes, but… this is why I can’t.” “Yes, but…” Whenever I hear “yes, but”-ing, I know that I moved too quickly and that I didn’t take enough time to fully drain, fully understand the problem. I find that when I do that and use strong words and body language to indicate I really get it, I really get how difficult and challenging this is for you and how important that function is, I’m not going to be getting “yes buts.” And if I can manage to not get into trying to fix it, then very often the solution doesn’t even come from me; it actually comes from the patient.
Chris Sandel: With that mini 5-area course that you were doing with people, where would they then filter into? If they raised their hand enough to say, “Yeah, I want help with this,” is that then going into inpatient? Is it going into outpatient? Is there a variety of different options that they could then go under?
Josie Geller: Yeah, exactly. When we did that clinical trial, we had this captive group of individuals who were basically sitting on a waitlist, so we figured rather than just sit them on a waitlist, why don’t we offer them something?
Depending on their level of symptom severity, they went all different places. Some of them actually just went on and were able to make changes in outpatient therapy, and some of them who needed more support would go for a more intensive treatment option. But what was so lovely about the RMT was that it worked no matter what level of readiness they were starting at and also what level of symptom severity, and also across diagnoses. It wasn’t just helpful for people with anorexia or bulimia; it had utility for all different eating disorders.
00:45:40
Chris Sandel: For you, then, as a clinician, what places have you worked? Has it mostly been inpatient, has it mostly been outpatient? Has it been a whole mix of different options?
Josie Geller: Yeah, I think I’ve probably worked in all different settings at this point. I do have a private practice, and I also worked in residential treatment for a while. I do just a little bit of work with our inpatient unit, although at this point I’m doing more program development, and meal support is something that I participate in regularly. We have someone sit with our patients and provide a normal eating environment, so I still do some things like that.
But more of my work right now is private practice from a clinical perspective. I have a little team of students, and we’re trying to learn as much as we can about readiness, and now also compassion and self-compassion, and trying to improve the treatments that we’re offering in the service that I work.
Chris Sandel: When you first started out, were you also starting out as being a researcher? Has that been something that’s been there the whole time, or that came later on?
Josie Geller: I thought I was going to be a clinician. I went into clinical psychology because I wanted to help people like I had been helped. I had zero – it wasn’t even on my list of things to be when I grew up to be a researcher. It really just kind of happened that I have a dear colleague here who was interested in doing one small research project, and we wrote a grant off the side of our desks without telling anybody because we were worried that that wasn’t what we were paid for; we were supposed to be doing clinical work, so that was a little side project.
But it got funded, and we ended up learning so much and finding that it was so helpful to the clinical work that we just kept doing more. In the research field, it tends to be once you get funding done, you are more likely to get more funding, so before I knew it, I looked like an academic. But it really wasn’t what I set out to do at all.
I just feel so blessed because I work in a clinical environment where this is the trenches. This is not an ivory tower setting where we’re just thinking up ideas. Everything that we research here is coming either from our patients or from the clinicians who work in the program. Every research project leads to some kind of change or improvement or informs the care that we’re delivering, which in turn gives us more questions.
I work with a group of clinicians who are now very research-savvy and who really enjoy having the opportunity to contribute to research questions as well as – we have a patient and family advisory group of folks who have graduated from our treatments who consult to all of our research projects, so it’s really closing the loop, having research that informs clinical practice and clinical practice that informs research questions. It’s quite a great place to work.
Chris Sandel: That’s probably why I’ve been so pulled towards your work because when I read it, I can see how practical it is for the work that I do. When I read through, it’s very clear that the people who are doing the research are also clinicians because, as you say, it’s not just coming up with theories; it’s like, “How do we make this thing better because we’re seeing clients day in and day out and we need to improve this?” Yeah, there are real practical, solid takeaways from everything I’m reading from the research side.
Josie Geller: Yeah. We were really interested in the stuff that doesn’t get talked about. Readiness and motivation was considered an airy-fairy kind of “can you really measure that?” This is back in 2000. It wasn’t something that was incorporated into our treatment models because there weren’t research studies with evidence showing that it mattered.
I think what we’ve always been interested in doing is operationalizing those airy-fairy things and actually turning it into a hard variable that could be assessed and that could then be looked at as a predictor of outcome. I think that’s maybe one of my biggest goals, to just find ways to identify and measure these ephemeral variables like what goes on in a relationship that promotes change, what goes on in a clinical session – not just what we’re doing, but how we’re doing it that may have a significant impact on outcome and the clinical care we provide.
00:51:05
Chris Sandel: Let’s go through some of the papers. As I said at the beginning, I think it’s going to be touching on both those areas in terms of clinicians being better, but also the readiness piece that we’ve been going through. One of them is “The relation between patient characteristics and their carer’s use of directive versus collaborative support stance.” I’m going to use this as the overarching paper. When I went through, there were many papers that were all around the same topic, just from slightly different angles.
Do you want to just give a bit of a description about what this paper was or what the papers in the same guise were about?
Josie Geller: Similar to what we were talking about earlier, I always felt like there’s something different going on in the room when it feels like a clinician is pushing or pulling a patient to make changes. Even though they might be using gentle words, sometimes you can just feel it in the room when the patient and the clinician are not – I guess the best way I could think of putting it is on the same side. There’s a sense that there’s a “push me, pull you” thing happening, versus when there’s a sense that both are equally engaged, there’s a sense of shared goals, that it’s two people solving a problem that’s not in an individual, but a problem between the two of them.
We’ve even thought about making an image of what it looks like when the first case, where we would call it “directive care” – I would think of it as a big giant clinician with an arrow pointing down at the patient, and they’re trying to get the patient to change, to eat more, gain weight, or stop binging and purging. They have an agenda, and their agenda is to get the patient to change.
In contrast, collaborative care, which would be characterized by the clinician not making any assumptions about anything that’s going on with the patient – and that’s a really easy thing to say, but sometimes a hard thing to do in practice. The only way that we can really get away from making assumptions is to have this beautiful, open, blue sky curiosity of just asking open-ended questions.
The collaborative clinician will make no assumptions, and they use words and body language that show that their aspiration is to help with what matters to the patient. It’s not “I want you to gain weight on my agenda or eat this way,” but actually to be genuinely curious about what matters to the patient – and also, for the concern and caring that they show the patient to not be contingent upon the patient’s behavior or performance. Basically, it’s positive regard no matter what you say.
I think that really has an impact. Sometimes I think eating disorder patients have finely-tuned antennae and they can tell, “Oh, I see. You like it when I say I’m motivated to change and you are less happy when I say that I didn’t have breakfast, so maybe I’ll just modify what I say to you so that you like me more,” but we’re not actually having authentic conversation anymore. So part of this stance is “I’m going to like you whether you are changing or not, whether you’re doing what you think are recovery behaviors or not.” It sets up a different kind of relationship.
Finally, another component of collaborative care is maximizing patient autonomy, making sure that they always have choices – in fact, they’re involved in whatever treatment goals we have. It’s something that we came up with collaboratively.
Just like readiness, we were so interested in these two different styles, where there’s more of a directive approach going on where patients are being pushed or pulled to do things, compared to a more collaborative approach where there’s two individuals working together on some goals in the context of a frame that they’ve agreed on, that they think will be most helpful and therapeutic.
We actually found a way to operationalize not what we’re saying, but how we do it, and created a measure of both collaborative and directive treatment and then looked to see the impact of collaborative care versus directive care on our patients.
What we found, not surprisingly, even though it was something that we weren’t sure we could really operationalize, is that we could operationalize it, and the more that our patients experienced the care they received as collaborative, the more satisfied they were with the treatment, the more supported they felt, the more acceptable they felt the care to be, and the more they had improvements in their symptoms over the course of treatment. We found that actually, patients had a very clear preference for collaborative care, but clinicians and family members also agreed that collaborative care is likely to be most helpful. So there’s kind of a universal acceptance that collaborative care is what patients and clinicians want.
But then the kicker, the amazing finding that we had I think in three or four papers, is that despite this preference that we all have, that clinicians, family members, and patients have, in actual practice, more often than not – I think one study was 76% of responses; another study was about 60% of responses – clinicians and family members are behaving in a directive way, even though they believe that collaborative is most likely to be helpful.
That got us scratching our heads as well. [laughs] We were thinking, we’re all wanting to offer this open, lovely, curious, nonjudgmental stance, and yet somehow, when the chips are down, we are behaving in a more directive way.
That’s gotten us interested in, well, how is that? It seems like it’s a common situation that we find ourselves in. What is it that’s contributing to us not using the stance that we consider to be most helpful, or what are the factors that are associated with us being more collaborative?
We’re still investigating that, but we have a few ideas so far, and I’m sure we’re going to continue learning more.
00:58:10
Chris Sandel: Let’s start with what are those ideas? What do you think is making that discrepancy? I can’t remember if this was in the paper or I watched something when you were talking about this – there might be something on YouTube of you doing some seminar or something, and you were talking about this discrepancy between what people believe is helpful and then what they do in practice.
Josie Geller: Exactly. The first one, and this is the most consistent one – this has come out a few times, and it’s what we might expect. If I believe that being directive is going to help, I’m more likely to be directive. If I believe that telling someone what to do, or perhaps offering an unsolicited opinion, is going to knock some sense into them and get them doing what they need to be doing, then I am more likely to be directive.
Similarly, if I believe that being collaborative which is showing concern and caring for the individual whether or not they’re changing and being encouraging, which is to maybe offer some choices, but where the individual still has the right to say “no” and nothing bad will come to them – in other words, “Here are some ideas. Would it be helpful if I were to do X to help you with your eating?” or “Would it be helpful to talk to someone about some of the difficulties? It’s okay for you to say ‘no’,” if I believe that those kinds of interventions are helpful, I am more likely to be collaborative.
At a very basic level, just plain education that directive is less effective than collaborative could be helpful. Our beliefs impact how we behave.
We’ve done a couple of studies, one that was on family members and one that was on clinicians. The one on clinicians is actually very hot off the press, but the one on family members indicated that it also helps if I have both positive and negative experiences with my loved one.
A predictor of being directive is only having negative experiences, so if I associate perhaps my daughter with difficult emotions or feeling like we’re getting into power struggles or feeling like my life is being impacted in a negative way, then I’m more likely to be directive with her. If I continue to have loving, positive interactions with her and I still see her strengths and the things I really admire and appreciate about her, then it’s easier for me to show that positive, unconditional regard for her.
If I have a combination of positive experiences, really enjoying my time with her, continuing to admire and appreciate her as a person, but also noticing that sometimes having an eating disorder has some difficult parts to it – if I can balance the positive and negative, then I may be more likely to use an encouraging response, where I’m talking with her about the eating disorder, I’m offering her choices about making change, but also, it’s okay for her to say “no.” It’s an ability to balance the positive and the negative and not see only the negative that can be associated with using that encouraging collaborative response.
Chris Sandel: Yeah, I think the bit that I remember is pretty much as the negative emotions associated with the situation go up, the more likely you are to be directive. If you’re like “Oh my God, this is such a worrying situation,” you’re less likely to be collaborative because you’re like, “No, it’s got to go in this direction.”
Josie Geller: Yes. It seems like fear is a driver of being directive and jumping in and trying to fix a problem. I think that would apply to us as clinicians as well. When we feel like something terrible is going to happen, it’s hard to maintain a collaborative stance.
Chris Sandel: When I would reflect upon myself with clients through the years, definitely that came up, where it’s like, “Okay, now I get this.”
Josie Geller: Yeah. A great example – when I’m teaching and I’m talking about the benefit of collaboration, I’ll almost always have someone, and usually it’ll be a physician, who will say, “Look, this is all very well that it feels better to be collaborative, but there are some situations where we need to make a decision and the patient cannot have any choice because they might die.”
This is going to sound like a pretty extreme example, but I think it’s helpful to say, even in those really difficult positions, let’s say when an individual is so underweight that they may be having some cardiac abnormalities and electrolyte imbalances, and they may actually be at risk for a heart attack, and we know that they need to receive some nourishment and they’re refusing to eat any more, I still think that it’s possible to have a collaborative discussion.
When challenged about what that would look like, what I would say is part of working in a collaborative framework is to have an understanding of the larger context in which we’re working. I might say, for instance, “As a physician, part of my job is to not let you die, so there are some things that do need to take place here today in order to ensure that you’re safe. However, you will always and still have some choices. Would it be okay if I talked about your choices with you?”
The choices that they could then provide – and I just want to say upfront, I understand that these would be horrible choices from the perspective of an individual with an eating disorder who’s terrified of gaining weight, and yet they still are choices. The choice might be, “Would you allow me to insert a nasogastric tube so that you can receive some nourishment? Because I understand that eating isn’t something that you’re able or wishing to do right now. So that would be one option, for you to allow me to insert the NG tube. The other choice would be for us to restrain you, either physically or with medication, so that we can insert a nasogastric tube.
“And I get that those are horrible choices because neither of those options are things that you would wish for right now. However, it is still your choice, and I would like to help you make the one that is going to work best for you. Which would be most helpful?”
I recognize that those are not ideal conditions, but from the patient’s perspective, it feels very different from being told “You have no choice. This is what’s happening now.” The encouragement – and sometimes when we do training about this kind of thing, I would just ask all of us to reflect upon, whatever setting I’m in and what’s going on in my practice, what actually are the ways in which we can operationalize collaboration in this environment? How can we make sure that that’s always part of our philosophy and model of care?
Chris Sandel: Just the way that you explain that, the thought is then as time goes on, you’re creating this relationship that then means the likelihood of them getting better and better gets increased. Yes, there’s a fear that in this specific moment, this person could die and we need to do everything in our power to stop that, but if you’re doing it in a way that makes it more likely that you’re going to come up against resistance the next week and the next week, there needs to be a level of context that is brought into the room around that.
Josie Geller: Exactly. We were really surprised; we did one small study where we actually asked patients who – kind of their worst case scenario, who had been sectioned or certified and come into hospital against their will because there was concern that they may die, and we asked them about their experience of what we now call treatment non-negotiables, basically a certain part of the therapeutic frame where there are certain things that needed to happen.
We were surprised that there wasn’t a single patient that said that they had a problem with the fact that there were non-negotiables. They understood that as a physician or a clinician, I’m committed to making sure that you don’t die, and it’s okay that I had some things that needed to be implemented. They didn’t have a problem with the fact that we had non-negotiables.
But they did have a problem with the way that they were implemented. They said, “I’m okay with non-negotiables as long as there were no surprises, something didn’t get sprung on me out of the blue without there being some warning.” One of the most important things was that there was a sound rationale for what was taking place, that somebody could look me in the eye and explain the reason that something was going to take place, and it didn’t look like their eyes were darting around or they were uncomfortable. It looked like they understood and also believed that this rationale made sense.
They also said that they needed there to be consistency. If we say we’re going to do something, do that thing. If we say we’re not going to do something, don’t do that thing. Across time, across patients, across admissions, just have that consistency.
Then lastly, they said they were okay with us having non-negotiables as long as they still got to make some choices. In other words, they’re actually not having a problem with the fact that we have non-negotiables; they’re having a problem with our skill in implementing them.
One of the most important pieces of work that we do here on our clinical teams now is ensuring that as a team, we’re very clear about what we’re doing, why we’re doing it, that we follow through consistently across clinicians, across patients, and always offering choice to our patients, no matter what the scenario.
We find that it leads to very different relationships with patients. Maybe this admission, they had zero interest in coming in; the next time they come, they at least don’t have this horrible association with the team. In fact, they remember “Oh yeah, those were people who looked me in the eye and explained what was happening, and I could work with them again” versus “I never want to see those people again.” [laughs]
01:09:45
Chris Sandel: Another paper that I think connects quite well to this – I know it’s also a fairly recent one – is “Barriers to self-compassion in eating disorders.” Do you want to talk a little about this one?
Josie Geller: Yeah, sure. As we’ve been talking about today, I was obviously very interested in exploring the idea of readiness for behavior change, and found out that it was such a strong, powerful predictor of outcome that we ended up doing 10 years of work to figure out how to address readiness and the relationships that promote improvements in readiness, etc.
We recently discovered another variable that also predicts outcome. I know that you’ve had some opportunities on your podcast to talk about self-compassion, so I’m guessing some of your listeners may be aware of the importance of self-compassion to overall wellbeing.
Self-compassion is different from self-esteem; it’s not basing my feelings about myself on my performance and how well I do at things. It’s about, depending on what definition, being mindful, knowing that I’m not alone when I’m experiencing difficulties, having the courage to feel difficulties and engage with difficult emotions, and then having an aspiration to be nurturing to myself and to alleviate suffering in myself, depending on the different definitions that are out there.
Chris Sandel: Which is based on a lot of the work of Kristin Neff and Paul Gilbert, are the two big ones there.
Josie Geller: They’re the big ones. Kristin Neff and Paul Gilbert, I think those are the two models that are most out in the research literature because they’ve come up with some lovely tools to evaluate self-compassion and show its relation to positive health indicators like resilience and overcoming illness and positive relationships. Pretty much anything that we look at seems to be associated positively with self-compassion.
So we started looking at self-compassion in individuals with eating disorders, and what we found when we did a focus group a little while ago was that our patients, rather than have this natural attraction to self-compassion, actually expressed a lot of barriers to practicing self-compassion. In fact, one patient I remember in a focus group said, “Oh my God, if I were to practice self-compassion, I would have to give up my eating disorder, and I’m not ready for that,” almost like it was threatening to consider having self-compassion.
We became very interested in that, and Paul Gilbert, who’s a brilliant clinical thinker, had actually developed a measure of Fears of Self-Compassion. We started to give it to our patients, and what we found was that having fears of self-compassion – or we even thought about it a little bit as readiness to practice self-compassion – was a second predictor of outcome.
This is really cool. There’s readiness for behavioral change, which we’ve been looking at for many years, but now there’s this other variable, readiness for internal self-compassion, internal change, or readiness to be kind to myself, that was also predicting outcome in both our inpatient and our residential treatment.
This feels like it’s opened up a whole other area. How is it that some of us are ready to be kind to ourselves and some of us are not so interested? So we’re trying to learn more about that right now. One starting point in the study that you just mentioned was we wanted to know, what kind of barriers do people with eating disorders have to practicing self-compassion?
We did a big factor analysis of the fears of compassion that Paul Gilbert came up with, and we actually found that individuals with eating disorders have two very distinct different types of barriers to self-compassion.
The first one is what we call “meeting standards.” This is the concern that “If I were to practice self-compassion, I would lose my competitive edge. I would stop working so hard. I wouldn’t push myself. My flaws would show. People would reject me. I would lose something important to me. My sense of identity would be lost because I would cease to strive and push myself, and I would ultimately get rejected.” So that’s one of the fears. I don’t know if that resonates at all with your patients or with people that you know, but it’s one of the fears that came out.
What we found is that the meeting standards barrier is most highly associated with, interestingly, readiness, early stages of treatment. If I have more meeting standards barriers, I’m less likely to show readiness for behavioral change, for behavioral recovery. It’s just too threatening to think of practicing self-compassion.
The second barrier we call “emotional vulnerability.” This is the barrier that “If I were to practice self-compassion, I may not even feel like I deserve kindness, or I may feel that I would be confronted with difficult emotions that feel overwhelming to me. It’s too much for me. It might put me in touch with times that I’ve been incredibly unkind to myself or perhaps with emotional experiences involving others who were unkind to me. It’s just too painful for me to go there. And it may even be foreign. It may be so unfamiliar that I don’t even know what that would look like.”
That barrier, which we call emotional vulnerability, is more about fear of feeling deeper feelings, like the difficulty of going into some of these emotional experiences that would be quite painful.
What we found is that those kinds of barriers – fear of emotional vulnerability or concerns about emotional vulnerability – are associated with long-term recovery. People who go into our more intensive programs, who are doing the harder work of emotional regulation and understanding the function of the eating disorder and addressing relationship difficulties and so on have a much better chance if they have fewer emotional vulnerability barriers.
That’s about as far as we’re at right now. We’re starting to develop now interventions that specifically target and address each of those barriers. We’ve actually found that meeting standards barriers can be addressed without too much difficulty. It’s lovely that there are so many great measures out there; we now know that it is not the case that if you practice self-compassion, you will become a non-achieving sloth. [laughs]
Actually, the data is not supportive of that. In fact, it’s supportive of the opposite. High-achieving people are doing so not because they only feel that they’ll be okay if they achieve something, but actually because they have joy in the process. They’re passionate about the thing that they’re doing, and practicing self-compassion is not associated with them deciding not to try anymore or not to strive or push themselves in any way.
So the meeting standards barrier can be addressed – sometimes I’ll just throw one of the articles on my desk to a patient, and that takes care of it. [laughs] Or sometimes it could be as simple as a behavioral experiment, like, “Let’s just try. What if you tried for one day to, as much as you can, remember to practice kindness to yourself as opposed to being self-judgmental or critical? Let’s just see what happens. Is your day better or worse? Do you get more done or less done?” Those little behavioral experiences sometimes can go a long way in shedding a light on what really happens.
We’re still working on emotional vulnerability stuff, but I know it’s going to have – in our qualitative work, we’re hearing a lot about the importance of being in a validating environment, not being dismissed when painful experiences come up, hearing from others that it’s okay to have difficult feelings, that others have had difficult feelings. And having some tools to cope with difficult emotions when they come up, such as when we get into DBT, dialectical behavior therapy, or learning emotional regulation skills, those kinds of things make it a little bit less scary or threatening to start feeling feelings. We’ll hopefully be learning more about that as this research goes on.
Chris Sandel: Nice. When I came across this paper, I looked up the Fear of Compassion scale and have now been using this with clients. I find it great. The scale – you talked about it being broken down into two areas, or at least two areas of interest for you, where the scale has got three different areas: expressing compassion for others, responding to the expression of compassion from others, and then expressing kindness and compassion towards yourself. For each of those, there’s a load of different questions, and you’ve got to say whether you agree or disagree.
It’s really interesting to see where people come up with their various responses and then getting them to redo the test a couple of weeks later or a month later. I had something recently with a client who did it and I said, “It’d be interesting to do some writing exercises based on some of these responses,” and she went back and before doing the writing exercise, she was like, “Actually, I’ve changed my response to a load of these questions.”
Josie Geller: Wow, yeah.
Chris Sandel: Which was great. And then in terms of you talking about the meeting standards piece is often the easier one to solve – I’ve got a writing exercise I do with clients which is called self-criticism as a motivator, and just starting to look at all the ways people use it, and then what would a nurturing friend say. Just by going through that process, they get to the place you were talking about. They’re like, “I don’t know if this is the right approach for how I want to be talking to myself and thinking about things.” So yeah, I would agree that that’s probably the easier one to tackle.
Josie Geller: Definitely. And I love the idea that you’re using these writing exercises, because I think it engages a different part of the brain to be writing things down. Also, it’s so nice to be able to go back to it afterwards and remember, “Oh yeah, there is an alternative to the way that I’m approaching – using a self-critical stance is one option, and there’s other options too, and what does it feel like when I use that one?” That’s really helpful. We use letter writing exercises here as well, and I think that’s a really nice way to start building a different way of relating to oneself.
01:21:35
Chris Sandel: Nice. I haven’t personally read any of Paul Gilbert’s stuff apart from looking at that scale he’s created. We had Kristin Neff on the podcast recently, and I’ve read her book, and I think she does really great work. But yeah, either of those are definitely people that listeners should check out.
Josie Geller: Yes, definitely. One of the things that I love about Paul’s work is he made that distinction between – this has just come out with Kristin Neff as well; I don’t know if she talked about it – but there does seem to be something different about compassion that is turned inward versus compassion turned outward, toward others. Both of them have now developed measures of self-compassion as well as compassion for others.
As you mentioned, Paul is talking about fears of compassion toward myself as well as fears of compassion toward and from others. Although there are some similar mechanisms in the brain that get activated when we’re experiencing compassion, whether it’s toward self or others, there are also some really interesting and important distinctions in what’s going on when we’re having self-compassion versus compassion for others.
I used to think – I expected that there would be a very high correlation. If I’m compassionate towards others, then for sure I’m going to be compassionate to myself. Actually, that’s not necessarily the case. It kind of makes sense when you think about it. You probably can think of some clinicians or some patients who are actually really good at being compassionate for other people, but who actually may be quite hard on themselves.
So it’s not always the case that having one will lead to the other. There may be different things that are helpful to cultivate to promote compassion inward versus compassion outward.
Chris Sandel: And it typically works in the direction that you talked about there. I don’t know if I’ve come across someone who’s really self-compassionate and then super critical of everyone else.
Josie Geller: Good point.
Chris Sandel: Normally what I’ve found with clients, especially with eating disorder recovery – and you talked earlier on in terms of weight and shape – people can definitely get on board that it’s okay for other people to be different shapes, or it’s okay for other people to have these different needs, etc.; it’s just that “I’m the special case that isn’t allowed that thing.”
Josie Geller: Exactly. You’re absolutely right. I don’t think we’ve found too many people who have high self-compassion but don’t practice compassion for others, but the opposite does seem to be true.
We found with some of our patients who have the lowest levels of self-compassion – this would be particularly, for instance, in our inpatient unit, who are really quite ill and really fearful of making changes to their eating disorder – that it’s actually helpful to not begin with self-compassion, but to help them begin to access compassion for others first.
What we’re finding is that they often have a much easier time, for instance, seeing another patient in a group and hearing that person’s struggles and engaging with that person’s suffering and wishing kindness and for that individual to be more compassionate for themselves. By starting out with compassion for others, we’ve had some of them later on identify, “Wait a minute, how is it that they’re worthy of compassion” – they see that it doesn’t make sense for them to be so hard on themselves for their experiences or for what they look like – “Well then, why not me? Why couldn’t I do that for myself as well?”
But that only comes after they’ve had the experience of having compassion for somebody else. I think what we’re learning is that there’s lots of ways to go about this, and in some cases, starting with compassion for others may be an easier way in than starting with self-compassion, which might feel scarier and more foreign for some of our patients.
Chris Sandel: Definitely. I would agree with that because you can then start to explore, how is there this cognitive dissonance where it’s okay for someone else but not okay for you? You’ve then got almost that bridge that’s there to start playing around with that as a concept. But if there’s neither of those things, then it’s very difficult.
Josie Geller: Exactly, yes. Interestingly, hot off the press, we just collected some data on clinicians in looking at determinants of collaborative care, because that’s another thing that we’re interested in. I was thinking that clinicians who have more self-compassion will be more likely to report collaborative care, but we looked at self-compassion as well as compassion for others, and compassion for others was a much stronger predictor of collaborative care than self-compassion, which I think is really interesting.
We’ll be looking at ways that we as clinicians can promote more compassion for our patients, because apparently that’s more important in promoting the delivery of that collaborative care than is self-compassion.
Chris Sandel: Wow, that is interesting. I’m also thinking bigger picture, though, if there’s not enough of the self-compassion, is that person going to be more likely to be burnt out because there’s less of the boundaries? I don’t know if those two things are connected.
Josie Geller: That is such a great observation, because that is the case. Self-compassion in clinicians is related to burnout. If I have higher self-compassion, I’m less likely to get burnt out as a clinician, but in terms of my practice of collaborative care, it’s compassion for others that makes me more likely to practice collaborative care. So we really need to get them both going, don’t we? [laughs]
01:28:00
Chris Sandel: Yeah. I’m conscious of time, and I’ve got so many different papers in front of me that I wanted to go through, so I’m going to just rattle off a couple of titles and then you can say “I think this would be the better one to go through.”
There was one in terms of “Is stage of change enough? Confidence as a predictor of outcome in inpatient treatment for eating disorders,” and then there were two papers looking at a similar thing, “Preferred therapist characteristics in treatment of anorexia nervosa” or “A qualitative analysis of aspects of treatments that adolescents with anorexia identified as helpful.” Any or all of those that you want to start with?
Josie Geller: We’ve actually touched on a lot of – in terms of the patient characteristics, it’s kind of cool when you come at a question in a bunch of different ways. I think one of those papers was with some colleagues from Norway; one of the papers was in an adolescent population. We have a couple of papers that have looked at qualities of clinicians in adults or in individuals with eating disorders who are in adult treatment centers.
We get this consistent set of variables of what patients are saying they want. It’s factors that are associated with alliance, where they feel that the person is showing interest in them not just as “an eating disorder” but as a person. In fact, one of the big pet peeves that I hear from patients is that they feel like they were just treated as a number that needed to go up on a scale or some symptoms that needed to change. They are really looking to feel that this person has interest in them and what matters to them, that shows interest and demonstrates understanding for their feelings. I think that validation piece is so important.
So there’s that alliance piece of being genuinely interested in me without judgment, and then there’s the other piece of whatever it is that goes on, the client is involved in decision-making. There’s always an emphasis on them having choices, and possibly even thinking of change as an experiment as opposed to an expectation that I have.
I’d say those are the main themes. There’s some little bits and pieces that come out of there, but what we found also is that the lower a patient’s readiness for change is, the more sensitive they are to these clinician characteristics. They really care even more so about not making assumptions and always offering choices.
I think in a couple of those papers, patients have said, “I really want someone who has expertise in eating disorders,” but usually when we break that down in terms of what they’re really sensing or caring about, it’s us just not making assumptions about their thoughts and feelings or sounding like we already know where they’re coming from, but always maintaining that curiosity and interest in the factors that have led them to be where they are at that point.
I think a lot of these factors are also not exclusive to clinician-patient relationships, but they’re kind of what we’re all looking for in relationships. I don’t like for my friends to make assumptions about me. I think we’re a lot more similar than different in what we’re all looking for in relationships, whether they’re therapeutic or just friendships or other kinds of interactions that we have with other humans.
Chris Sandel: Definitely. When I went through these various papers, there was one that stood out a little bit in terms of a comment where people were talking about liking a sense of humor. As part of the qualitative bit, they were talking about that it felt that, “I’ve got in some sense this life-threatening disease, but we were able to have a laugh and the tension in the room wasn’t there,” and how important that was. That was definitely something that I reflected upon within myself. Through all of this, I’m always having a laugh – within the right places – but I can definitely get a sense of where someone’s at as that starts to come through more and more.
Josie Geller: Totally. That’s such a great point and touches on a couple of things. One is I think our patients really want us to be ourselves. When we used to train students to do the Readiness Motivation Interviews, I felt very strongly that they should not do the interview the way I do it. There were the basic principles and stance elements that we wanted everyone to have, but ultimately, it was most helpful and effective if they made it their own, and it was each individual interviewer’s style of doing the interview so that there was a sense of authenticity, of it being two humans meeting, not a robot meeting a human and expecting to get human responses. [laughs]
That ties in with this wonderful comment that was made by a patient recently. We were doing qualitative interviews with patients who were recovered to ask them about what helped them to overcome barriers to self-compassion. We know that these barriers are so important, and we asked them, “What was helpful for you?”
This patient commented directly on her relationship with her therapist, and she said a turning point for her was when the therapist not only espoused practicing self-compassion, but actually showed that she herself had difficulties and times of embarrassment and could practice it with herself. Apparently, the therapist gave this story about tripping and falling in the subway station or something and being really embarrassed, and then using self-compassion to remind herself that everybody stumbles and feeling embarrassed is part of the human condition, and that she could actually have a laugh and be kind to herself, and she wasn’t this perfect person that always does everything just right and doesn’t feel embarrassed.
The way that the patient said it, which I thought was just so beautiful, was she said, “Don’t tell me to practice self-compassion. Show me. In other words, walk the runway. Put on the garment, walk up and down the runway. Let me look at you. Let me touch the fabric. Let me see how it flows on you, and let me make my decision based on how I see it looking on other people as well.” I just thought that was such an equalizing – it’s kind of like humor work and being human work. It’s helpful for patients to see models of humanity, and much more hopeful and encouraging for them to see that than for it seem like recovery is so far away and everything is so perfect that it’s out of reach for them.
Chris Sandel: Definitely. It’s come back to what you talked about at the beginning in terms of the more directive approach versus collaborative, and when directive, the image is someone who is big and is talking to you or talking down to you and what that symbolizes, whereas it’s more just two humans having an interaction.
This is something you learn as you go along and have experience with it, but maybe in the beginning, there’s a feeling of like “Oh gosh, I don’t want to show that human side. I’ve got to show that I’ve trained. I’ve got to show that I’m an expert. I’ve got to prove to this person why they’re paying this money or why they’re here.” Then with time, that goes away because you realize none of those things really matter.
Josie Geller: Yeah. I think there definitely is an early part of our training where we may feel like it’s not as easy to show that sometimes we’re terrified ourselves of saying the wrong thing or doing the wrong thing. But I think ideally, we get through that self-conscious period as quickly as possible as learned clinicians, and really allow our humanity to come out. I think that the patients appreciate it and do not evaluate us negatively, but actually see it as a strength for us to be humans.
I’ll regularly talk about my own meditation practice or ways that I’m using some of the skills I’m teaching, that I’m using them in my own life as well. I think that does bring us to be more the same size rather than me being giant and them being small.
Chris Sandel: The relationships that I have with, say, longer term clients, it feels like they know lots about my life, and I think that’s important. I think sometimes it can feel like – again, in the beginning, it’s like, “Am I wasting time on this?” But it’s like, no, this is about developing a relationship and developing rapport, and it’s important.
Josie Geller: Yeah, I think so too.
Chris Sandel: Josie, this has been fantastic. I’ve really loved being able to cover all of this information with you.
Josie Geller: Same. I’m impressed how much ground we covered, Chris. I’m really impressed with how much you were able to learn about the stuff that we’ve been doing here. I’m very flattered, and I really enjoyed this.
Chris Sandel: From my perspective, I’m glad you’re doing this work, because I’ve found it very helpful. It is helping me to be a better practitioner, which I hope is great for you because it seems like that’s a big part of your goal with this stuff.
Josie Geller: That is. That really is. Nothing could please me more if it’s of any use to anyone out there.
Chris Sandel: I’m going to put links to various things in the show notes. Where should people be going if they want to find out more about you? Is there anywhere on the web that you want to be pointing people towards?
Josie Geller: We are complete luddites around here. We have no real social media presence. Unfortunately, at the moment, I guess research articles would be where they could learn more about us. There are some very small writeups of us here at St Paul’s Hospital, but I think you’ve probably highlighted something that we need to get better at and have this stuff be made more accessible. Which is why I’m so grateful for you to invite me to have this conversation with you today.
Chris Sandel: Perfect. Thank you so much for your time, and I hope we can chat again in the future.
Josie Geller: Same. Thanks again.
01:39:35
Chris Sandel: That was the interview with Josie, a pretty amazing individual. As I said at the start, I was really blown away when I came across all the papers and the work that she’s been doing and how relevant and practical it was for me, so I hope you feel the same way and you got a lot out of listening today.
I have a couple recommendations for things you might want to check out. I haven’t done this for a handful of podcast episodes. There’s so much I’ve been watching and listening to, but I’ll just pick a couple of things.
The first is a podcast episode. In my end-of-year roundup, I mentioned that one of the podcasts I enjoy is Broken Record. This episode is from that podcast, and it’s an interview between Andre 3000 and Rick Rubin. Andre 3000 is one half of the hip-hop duo OutKast. I was a fan of OutKast; I was never a huge fan, but I had some of their albums and I enjoyed what they were doing. But the last album they put out was back in 2006, and since this time, Andre 3000 hasn’t put out much music. While calling him a recluse is probably too strong a word for someone who sold 25 million records, it’s amazing how little music has come out since that last album.
This is actually what the episode focuses a lot on: Andre 3000 talking about his struggles with social anxiety, about being highly sensitive, his fears about trying to make something new when the stakes feel so high – previously, there would be no expectations, but now he feels everyone, including himself, has such a critical eye on anything he does – and how this can be paralyzing in making anything, or at least, getting further than just playing around on the piano or some instrument. He talks about the isolation of fame and how much it disconnects you and separates you, and how he now spends most of his time alone.
For me, there’s some really refreshing honesty and openness with conversations like this. Yes, it can be dismissive to think “Wow, he’s this multimillionaire, a Grammy Award-winning artist; quit your complaining,” but for me, hearing Andre 3000 talk about his struggles just shows the common humanity and insecurities that we all have, and that there’s no amount of money or fame that takes this away.
Rick Rubin is a great interviewer. He’s thoughtful and softly spoken and measured, but he’s also one of the most influential producers of all time, so his knowledge about music is incredible. He can ask questions and talk about music with Andre 3000 in a way that really appeals to the music nerd in me.
So if you’re interested, give it a listen. The podcast is Broken Record, and it’s Rick Rubin and Andre 3000.
The second recommendation is a documentary called Jane. It’s about Jane Goodall, the English primatologist and anthropologist. In 1960, Goodall went off to live in the Gombe National Park in Tanzania, and she wanted to study chimpanzees, which, up until this point, we knew very little about.
The documentary is made up mostly of all the footage that was taken at this time. She lived in the jungle for years. She lived with her mother. It shows how she slowly became accepted by the chimpanzees and then built a relationship with them, and then all of the things that she discovered through that and through the study of them.
It really is a fascinating story as she followed this troupe of chimpanzees over the best part of two decades. There were times when she was living there for extended periods; there were times when other people started to take over and live there, and she would come back and forth. But as part of that, you really get to see both sides, the best and worst of our human impulses and how they occur in non-human primates, from the love and tenderness that the chimpanzees are able to express for their young or for other people within the troupe through to the war and the murder and the genocide that they can inflict on members of the troupe that were once like family.
Considering how many documentaries and podcasts I consume that are pretty heavy and dark, this was at the lighter end of things and was filled with beautiful scenery. It was amazing to be transported to this place in the jungle and see how it was through the eyes of the original footage. So I recommend it. It’s called Jane, it’s on Netflix, and it’s worth a watch.
That is it for this week. As I mentioned at the top, Seven Health is currently taking on clients. If you’re struggling with dieting, disordered eating, recovery, body image, and any of the other topics that we cover as part of this show, then please get in contact. You can go to seven-health.com/help. I will be back with another episode next week. Until then, take care of yourself, stay safe, and I will catch you soon.
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