Episode 304: This week on the show I speak with Dr. Brad Smith, the chief medical officer for Rogers Behavioural Health. We talk about the co-occurence of many conditions with eating disorders: OCD, anxiety, depression, and addiction. We also cover ERP (Exposure and Response Prevention) - what it is, how it works and how it can be used for different aspects of recovery.
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Chris Sandel: Hey. If you want access to the show notes, and the links and the transcripts that are mentioned as part of this podcast, you can head to www.seven-health.com/304.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist and a coach and an eating disorder expert, and I help people to fully recover.
Two things I want to mention before we get started with this episode. The first is if you are watching this on video – and I’ve been mentioning recently that I’m doing these video podcasts now – if you’re watching on video now, you will notice that the background has changed or where I’m sitting has changed. You may also notice that it’s a little bit echoey in here, which I’ve only discovered as I hit record. It sounds more echoey than it usually does.
I was in an office next to here, maybe 10 metres away from here. When we rented the place that we’re currently in, the house didn’t have a good setup in terms of where I could have an office, and the people who were renting the house to us had another property next door to it that was a – we call it a granny flat over here. I looked it up; in the States it’s called an in-law suite. I don’t know what it’s called in other places of the world. But it’s like an extra property that has one bedroom, it’s got a kitchenette and that kind of thing. I’d been using that as my office, but it was a really big space for me to be using as an office. So I was chatting with the people who own the properties, and he is a builder, and they said, “Okay, we’ll build you a different office.”
So where I am currently sitting used to be where there was a jacuzzi and a roof over the top of the jacuzzi, and we were never going to use that. So they just took out the jacuzzi and then they whacked up this office. It’s a lovely new space. It’s a better size for what I actually need as an office, and then I don’t know what we’re going to do with the other place. There’s different plans that I have, that Ali has, that Ramsay has in terms of what that space will be turned into, but in the immediate future, my parents arrive this Thursday, so they will be staying there and they have a nice place where they have their own shower and their own space while staying over here.
So that is thing number one. If you hear it being a little bit echoey, that is the reason. I don’t know what I’m going to do. I’ll see if I can find something. Or maybe it’s not really a big deal and it can just stay as it is. So if you’re wondering why the background looks a little different, that is why. And I’ll show you – this is my pride and joy, my colour-coded bookshelf, which you can see over here. I’m constantly getting rid of books because I’m buying so many, and every time we move I get rid of some, but that’s where it’s at at the moment.
The second thing to mention is I’m currently taking on new clients. If you’ve been living with an eating disorder for a short time, a long time, I would love to be able to help with this. I know when living with an eating disorder, it can feel like there is no way out of this, this is permanent, and I don’t believe that to be true. I totally believe that you can fully recover, and I would love to help you do that.
When I think about what I focus on and the way that I work, I use a method called the transformational recovery method. This is what I’ve developed over the 15 years of working with people and figuring out the things that truly matter. The three main areas we’re working on are:
One, how you can fully recover from a physical standpoint, so doing the physical healing that is needed as part of that. What’s important here is this isn’t just the physical part of how to rebuild muscle and bone and organs and that type of thing that is really impacted upon by being in an eating disorder, but it’s also how the brain and the mind are impacted as well, because this has an impact on the kinds of thoughts and feelings and perceptions and beliefs and memories and all the things that naturally come to mind. Being in a depleted state has a really big impact on you and your experience, so it is looking at how we move you out of that state.
The second thing is looking at coping skills and developing resilience, because what typically happens is that an eating disorder becomes someone’s only way of coping, and we need to figure out and develop other ways of being able to do that. There are lots of different ways of being able to do that. It is then developing that area and really developing resilience in that area.
And then the third one is looking at how you can get your life back and bring more things back into your life now, not at some point in the distant future. I think there’s this misbelief about the fact that “I will do all this recovery work and then a butterfly will come out of the cocoon later on fully done” and that just doesn’t work. You need to be bringing things back into your life to really give you a reason to keep recovering and give you a reason for why you want to recover, because you’re now having these experiences of things that are coming into your life and you want more of these to be occurring.
So those are the areas we focus on as part of recovery. If this is something you want help with and this is something you have been, as I said, struggling with – either for a short time or a really long time – I work with people who have been struggling with this for multiple decades and help them to reach a place of full recovery. So if that is what you would like, I highly recommend that you send an email to info@seven-health.com and put ‘Coaching’ in the subject line, and I can get all the details over to you.
So on with today’s show. On the show, it is a guest interview, and today my guest is Dr Brad Smith. Brad is board certified in adult psychiatry and has experience treating patients in all levels of care. He is the Chief Medical Officer for Rogers Behavioral Health and was previously the Chief Medical Officer for their eating disorder services. He was named a Distinguished Fellow of the American Psychiatric Association (the APA), joining an elite group of psychiatrists in earning an accolade given to those who’ve made a substantial impact in the field.
He also serves as a voluntary assistant clinical professor in the Medical College of Wisconsin’s psychiatry and behavioural medicine department, where he teaches residents and fellows.
I became aware of Brad fairly recently. Julie on my team was someone who sent me a couple of podcasts that Brad was on, and I gave them a listen and I really liked what he had to say. When I dug into him and what he does, there were a couple of main areas that I was really interested in. The first was the co-occurrence of other conditions alongside eating disorders – things like OCD, anxiety, depression, addiction. So that is one of the areas that we talk about.
The other one is a thing called ERP, exposure and responsive prevention. This is a type of therapy or a type of modality that Brad uses and that Rogers use, and it’s something I haven’t talked about before on the podcast and I was really interested in it – really interested in it from a practical standpoint and what it looks like in a session and what the goals with it are. So that was the other thing that I was really interested in chatting about.
We cover both of those things plus lots more. I really loved this conversation with Brad. I’m often talking to individual practitioners or individual coaches, so there was something nice and different about the fact that I’m talking to someone who is a member of a team, and this real multidisciplinary approach that they’re taking. It just offers a different perspective than someone who is an individual coach like myself who is working in the outpatient setting. So that was great.
This was also the first interview that I’ve done where the video is recorded. This is recorded in Zoom at the moment. I have downloaded some other app for doing this moving forward, so that will come with some future episodes, but at this stage it was just what I recorded in Zoom. So if you want to be watching these instead of just listening, you can do that on YouTube or on Spotify.
So that is it. Let’s get on with the show. Here is my conversation with Dr Brad Smith.
Hey, Brad. Welcome to Real Health Radio. Thanks for joining me today.
Dr Brad Smith: Thanks, Chris. I’m very glad to be here.
Chris Sandel: You are the Chief Medical Officer for Rogers Behavioral Health, and I know you have this real background in treating eating disorders at all levels. There’s a lot that I want to chat with you about today, all connected to eating disorder recovery.
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Just as a starting place, do you want to give the listeners a bit of background on yourself? Who you are, what you do, what kind of training you’ve done? And then we can go from there.
Dr Brad Smith: Sure, happy to. I grew up in a small town in Wisconsin and then went on to college and then to medical school at the University of Wisconsin. I finished a psychiatry residency also at the University of Wisconsin, then did a year of subspecialty training in the field of forensic psychiatry at the Medical College of Wisconsin.
Then my career path was actually more in forensic psychiatry, where I worked at the state hospital in Wisconsin doing a lot of evaluations for court cases, like assessing people for competence to stand trial, assessing people for whether they were not guilty by reason of mental disease, and also then was providing treatment for many of these individuals after their court case had been settled. So a lot of broad breadth of psychiatric issues, severe psychiatric issues. Also interfacing a lot with community mental health in our local communities when we were trying to help people get back into the community from the state hospital.
Then quite a detour at that point: I wanted to start doing something different in my career from the standpoint of day-to-day work and started looking around for a place to do more general clinical work. Ended up landing at Rogers to be the doctor for their outpatient programme, which was partial hospital and IOP programmes in the Madison, Wisconsin area. Part of that programme was their eating disorder partial programme. I had been pretty comfortable with working with individuals with eating disorders based upon some training in my medical school time and my residency time. Not a lot of people get training in the medical field on eating disorders, but we happened to have a couple of rotations at the time that I had enjoyed.
So I was eager to take this on again. Shortly after starting there as the day programme psychiatrist, there was a need in their inpatient unit to provide what I thought at the time was short-term coverage, and 13 years later, I’m still doing day-to-day clinical work at Rogers over at their original hospital site, which is in a city named Oconomowoc, in the western suburbs of Milwaukee. Then I’ve really just grown up in the Rogers system in terms of my eating disorder practice over the last 13 years, and it’s been great. I’ve enjoyed all parts of that, whether it’s the staff psychiatry role that I originally played or even all the different administrative roles that I’ve played as the years have gone on.
Chris Sandel: Nice. There is definitely some follow-ups that I have. When you went originally to do psychiatry, was the passion going to be in forensics and that was always the career path that you thought about? Or it was more general than that, and you just found yourself in that place?
Dr Brad Smith: It was more general than that. In fact, first few years of the psychiatry residency, I wasn’t sure that’s what I wanted to do. It probably had something to do with our residency training at the time. I think it was good, but it just happened to focus a lot on pretty general outpatient practice where the acuity or the severity of the issues we were dealing with in a lot of our day-to-day work wasn’t as appealing or as challenging.
Then I did a rotation with someone who was doing forensic psychiatry and really thought, “This is a whole new playing field. This adds a whole other element of thought to the process, a whole new intellectual challenge.” So I started to learn more about that career path and went to a couple of national conferences around it, but then decided I wanted to do the fellowship in it. But no, it wasn’t on my radar at all as even a field. I really didn’t know much about it. That was before all of the TV shows like Criminal Minds. People now come up to me a lot, when they know that I’ve done forensic, and have all these questions or observations from the shows they’re watching. None of that was available when I was in training. This was a brand-new field I hadn’t known about until doing some of that work with an individual who was already doing it.
Chris Sandel: When I read that as part of your profile, that was instantly where my mind went, to the crime TV shows.
Dr Brad Smith: Right.
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Chris Sandel: So with the transition into working with eating disorders, what is it about that population or about that area that really interested you or drew you in?
Dr Brad Smith: One of the things that was unexpected around how there could be some connection there was really working with individuals as a psychiatrist who also had a lot of physical health issues or complications. At the state hospital, we had an internal medicine or primary care department, but it wasn’t resourced the way a place like Rogers is. The attending psychiatrist ended up picking up a lot of that initial primary care coverage. Things had to get to a certain level of severity before we were calling in the internal medicine department.
I’d gotten used to taking care of a lot of primary care issues. It was a little scary because that’s not the bulk of my training in residency, but that was a part of my 10 years at the state hospital. So when I started the work at Rogers and working with individuals who eating disorders, that was appealing to still have some aspect of the physical health issues and complications as a part of my role.
But it was much easier, in fact, because I have this great primary care team that I work with, and right off the bat in the first few weeks of working on the inpatient unit, I was like, “This is ironically easier than what I was doing from the physical health standpoint.” I had all this help, I had all these great mentors to work with. That really was the bridge. It was doing more than I think a general psychiatrist might do in an outpatient practice. It was having all these medical issues involved.
Then the other piece was just the complexity, that intellectual curiosity around, how is it that you start to peel back the onion layers of this complicated situation that people have? When I was in forensics, a lot of it had to do with these legal situations, and then oftentimes these really unusual or aggressive or severe behaviours that people were engaging in, and then trying to peel back those layers. I had this intellectual curiosity going in me.
I see that in eating disorders as well. As we all recognise, it’s very complicated. Individuals have complicated histories. Individuals have complicated current lives. All of these things working on them as a person, it’s very, very interesting. It’s very rewarding when people start to do the work or have success as they start to make those steps towards recovery. So a lot of similarities, but in some strange ways, that I found the connectedness.
Chris Sandel: As I’m hearing that and I reflect on my initial training and thinking about where I wanted to end up and how I’ve ended up where I am with working with eating disorders, it is that messiness of it that I find really fascinating. I enjoy being able to deal with it because there’s all these different components to it, and that is a lot more interesting than what I originally trained in, which is nutrition and telling someone how much protein they need or how much vitamin C they need or whatever. There was a lot of dryness to that compared to the work that I now get to do working with eating disorders. So I understand your enjoyment of the complexity side of this.
Dr Brad Smith: Yes. It really wasn’t expected or intentional to make that leap for those reasons. But people would say, “What is the connection and why does this appeal to you?”, and I also found that working in higher intensity areas for people with eating disorders, like inpatient and residential, a lot of it is around trying to help people to make these behavioural changes before they might actually be fully ready or convinced that that’s what they want to do, but there’s maybe a medical acuity or necessity to making those changes.
Even some of the characteristics or unfortunate components of eating disorders involve the secretiveness or the not being as forthcoming. Some of my colleagues have really struggled with that. I came from working in settings where being forthcoming with your doctor is not common. In a forensic setting, there’s a lot of effort volitionally to try to mislead the doctors at times. So it’s been refreshing with many individuals with eating disorders, even if they’ve had to be very secretive about their behaviours or their illness, I recognise and it’s easier because it’s not coming from a place of volitional malintent. It’s coming from a characteristic or a component of the disease process and a necessity to keep things under wrap.
So it hasn’t caused me to have a lot of personal negative feelings if people haven’t been fully forthcoming with me. It helps me to really connect with the parts of them that want to get better or the parts of them that seem like they’re ready for making that step, even if it’s only 51% of them that wants to get better. I really enjoy then trying to work the rest of the way with them to try to get it to a better place.
Chris Sandel: I wonder, how many of the people that you’re seeing in the setting – and maybe it’s more of the inpatient setting – are there because they’re truly choosing to be there versus there because their parents are sending them there or something along those lines? Because it’s interesting when I’m hearing you say about people not necessarily being forthcoming. Definitely that is occurring on some levels with people I work with, but I actually don’t find that it happens very often.
Maybe that’s because I’m in the setting where people are intentionally reaching out and wanting to work with me, and they will be telling me stuff that they haven’t told anyone else, but there’s a recognition of “There’s no point in me putting on a charade. There’s no point in me trying to say something that’s not true because Chris isn’t going to be judging me, Chris isn’t going to be doing anything apart from ‘tell me what’s going on and then we can figure out what to do with this information’.” So from my perspective, I feel that people are pretty forthcoming, but I’m also aware that I’m getting people who are selecting to work with me and it’s a different thing to possibly what’s going on with some of the people at Rogers.
Dr Brad Smith: I would imagine it has a lot to do with the correlation of the severity or intensity of the level of care that someone is in. Certainly when we have people in our less intense levels of care, we’re really at that point where everybody’s walking together and people are calling it out when their behaviours are slipping or something of that nature. Inpatient setting – and even though Rogers is a voluntary programme; it’s fully voluntary. We try to make that very clear when people are coming in or when families are twisting the arm of their loved one to come in that this is a voluntary programme. In fact, in our state of Wisconsin, involuntary treatment is really hard to actually even do. A lot of protections in the state for that.
So we need people to be volunteering to come in, but all the issues you just mentioned – it could be someone’s family is twisting their arm, it could be that their outpatient providers have said “We don’t think we can work with you any longer unless you go do this.” So they are coming in voluntarily, they’re signing in, but that could be a little bit fluid. They might be really convinced when they walk in the door, but then once they start to get acclimated to the unit or the programme it can feel very overwhelming at times, and then there can be a lot of wavering on how much they want to be there or how much they want to do it at this time.
We really try to work with that. It’s been something I really try to help impress upon our teams as well. Even if somebody comes in, gets overwhelmed, it seems like it’s not a success for us as a treatment team because they ask to leave after 48 hours or something, that is still possibly a very, very important piece of that person’s recovery because if they came in and they sized it up and got some awareness of what this might look like, what it might be like to participate, they might have to go home and regroup, but there’s a good portion of those individuals who will come back and then complete the process because they were so overwhelmed with the transition.
So yes, there are all different levels of readiness, and I think it’s fluid even after somebody has agreed to come in. I think we all deal with that ourselves in terms of we’re not always 100% committed to everything that we do. And this has many, many other elements to it for an individual making these important decisions.
Chris Sandel: Totally. One of the modalities I use a lot is polyvagal theory, and I think using that way of thinking in terms of describing and understanding the nervous system and the idea that we are always perpetually in a state, and in those different states we all have different kinds of thoughts and feelings and sensations and perceptions that come to mind – so yeah, there are points where recovery feels like the thing that is most important and “I really want to do it” and there’s all these reasons why, and then 20 minutes can pass, or 48 hours can pass, and someone feels very differently about it because something has occurred that has created this shift in their state, which causes other thoughts and feelings to come to mind.
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One of the things I wanted to go through before we dive into the stuff around eating disorder recovery and some of the things I want to talk to you about was more about you and your background in terms of your relationship with food as a kid and growing up. What was your relationship with food like?
Dr Brad Smith: Some components in my life that I think give me a lot of empathy and also help me resonate with the struggles that people have – I did not come from a background where I developed a full-on eating disorder, but I had some form of unhealthy relationship with food growing up. I was in a family where there was a lot of eating that was by today’s standards considered not the best practices, and a lot of free rein as a kid in terms of eating patterns.
Basically, it had gotten to a place where at some point of my middle school years, I was in a larger body than most of my family; my eating habits were a lot towards the types of things we think of now as causing health problems, whether it’s ultra-processed foods, a lot of free range on doing desserts. At some point that was affecting me as an individual in terms of I wanted to play sports, wanted to be healthy.
I had the good fortune of meeting with a doctor in our local community who I think was ahead of his time from the standpoint of how health and nutrition work together, and also set a path that was towards health and not towards anything that was probably more popular in the day with the diet culture. He started teaching me about try to make small changes in how I would eat so that it would be a lifelong process of doing better with what was happening with my health – trying to move away from ultra-processed foods and more “Why don’t we have things more from sources we know where they’re from”, trying to move away from as many desserts as I wanted to “Let’s try to eat more balanced and look at the macronutrients of things.” But not to do it in an ultra precise way, but just try to get a more balanced approach. The very things I see being taught all the time now in terms of proper balance of macronutrients and proper physical activity.
That really shaped my experience moving forward, and I was able to get to a better place in terms of how I would eat as part of a balanced meal plan. Helped steer me in a way that I wish, frankly, more people would have the good fortune of that experience where it wasn’t inundated with diet culture type material or recommendations. It really was about setting up a plan where your life has some physical activity, has the ability to have good food, rich foods when you want, but also try to find some balance in the macronutrients and how you eat moving forward.
It really helped me. It helped shape my interest in health. It helped shape my interest in medicine. And then I think that has helped me to have this experience where when working with individuals who have ended up in a very bad place with their relationship with food and developing eating disorders, it’s allowed me to have much more resonance with the struggles, much more resonance with how somebody can chart a path that doesn’t have to go down a path of an eating disorder if they can get some good information, some good encouragement and support early on in their life.
Chris Sandel: Nice. The thing that I hear with your story is often how so many people end up in an eating disorder. It’s amazing how many people start out with these good intentions where “I’ve been getting a lot more bloating or digestive issues. Let me see what I can change to help with that” or “I’m finding I’m a lot more tired. Let me see what I can do with this.” So going down the road where it feels like (1) this is going to be supporting myself and a really good thing, and (2) this feels somewhat innocuous – I’m not doing anything dangerous here, I’m not doing anything extreme – and then fast forward two, three, four, five years later and they’re in a completely different place, and not a very good place.
So it’s lovely to hear that you had this experience where you were able to recognise that there were things you were doing that weren’t leaving you feeling the way that you would like to be feeling, and you were able to change that – and do that in a way that is sustainable, that was enjoyable, that actually is something that you’ve been able to continue doing for the rest of your life as opposed to it being this very black-and-white or very all-or-nothing or very extreme way of making changes.
Dr Brad Smith: Right. I think that’s what’s really helped in terms of seeing the slippery slope that you described. That is such a common story that you just described: someone having the best intentions, starting to make some changes, getting some information that maybe isn’t the best, and then going too far, and the next thing you know it’s got control of a person’s life.
The other piece that probably helped me around that time, or helped the way that our family ate, was that my mom ended up getting type 2 diabetes diagnosed around just after I started to want to make these changes, and that changed her way of eating in our household. Then that also helped me to start realizing I was getting to an age where I was seeing that family history; my genes were a lot of people with type 2 diabetes, a lot of people with cardiovascular problems.
So I wanted to do whatever I could to put me in the best position possible for that sort of genetic profile as well. I was just very lucky with the type of advice that I got at the time. It’s been amazing to me how far ahead of the game I think the doctor I happened to see at the time was. At the time, it was not well-accepted or well-known; the very things we hear now as part of what we might think of as good advice from a nutritional standpoint, good advice from a physical health standpoint wasn’t really the main focus of physical health clinicians or even the field of dietetics at the time. I realize most days how very lucky I was that that was the person I saw at the time.
Chris Sandel: I also want to mention, because I know how these conversations can sometimes be heard by someone who is living with an eating disorder or in recovery, like “I now need to be on the lookout for diabetes” or “I need to be doing things to worry about my cardiovascular health” – I want to just remind everyone, context matters. There are things that Brad was doing that were applicable and helpful for him given the state that he was in versus the state that you may be in, and these things are largely irrelevant because the most important thing for you is not having an eating disorder versus what may be more important for Brad.
I’m just very aware of how these kind of conversations can be misconstrued and the eating disorder can jump on them and turn them into something that they’re really not.
Dr Brad Smith: Right. Appreciate that qualifier there.
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Chris Sandel: One of the things I heard you talking about on a previous podcast that I really want to highlight – you did a really good job talking about this – is just the seriousness of eating disorders. I think probably most people can understand the seriousness, but often when you’re in the midst of it, it can be hard to grasp this. I don’t think that fear is typically a very good motivator for people; it doesn’t have a very good, long-lasting impact. It momentarily may do something, but in the long run, not much.
But I think just starting out, the seriousness of eating disorders from your perspective, what would you say on that topic?
Dr Brad Smith: They’re extremely serious, and I agree with everything you just said, Chris. Fear is not a great long-term motivator, but it can help to set the stage for the importance of something.
One of my first years at Rogers in doing eating disorder work, I had been asked to appear for – I think it was the Eating Disorder Awareness Week, appear on a local TV spot, just a short segment. I came in with the idea of impressing upon the audience and anyone listening to try to seek help if they were feeling any sort of need, if they were feeling any sort of resonance with what was being discussed as part of the eating disorder awareness.
I’m typically a very positive person. I try to look for the hope and the recovery for individuals. It must’ve come across as being overly optimistic, but it landed pretty poorly on the parent of an adult individual, their child who had not made it with their eating disorder. They had died because of their eating disorder. So I heard from that parent, who connected with me later indicating she really wanted to impress upon me that it’s great to have this positivity around hope and recovery, but that as a professional in the field, called me out that I didn’t cover the seriousness of it. That really helped make me very aware that, as positive as I try to be as a clinician, as positive as I try to be as a person, and looking for ways to help people connect with their hope for recovery, I have to balance that with the seriousness of these illnesses.
That has really stuck with me, and I try to include that in any more publicly viewed type interview or statements that I make about eating disorders. That’s the sombre part of what we all talk about, what we all deal with, and of course that raises all of the reasons why we have to continue to work for more awareness and more ways of making sure people have access to care.
Chris Sandel: I think fairly similar to you, I’m someone who is very much full of hope, and I believe that everyone can make a full recovery and will always tout that message – and also, that there is seriousness to this. I put out an episode last year about the fact that I’d found out a client who I’d been working with prior had passed away. Yeah, it’s a horrible day to receive a message like that and to find out that’s where someone’s life had ended – someone who was in their forties, who had so much that could’ve been. So yeah, I definitely agree with you that we need to find this balance between giving huge amounts of hope and then also not making light of just how serious these things are.
Dr Brad Smith: The eating disorder is not balanced. It will continue to pound that message that “everything is fine, this isn’t a big deal, that blood in your vomit isn’t a big deal, losing your teeth isn’t a big deal, you can keep doing this.” Those are the messages that are going to keep coming. I try to know that I need to keep providing the information about, here are the facts around it. When these things are happening, here’s what’s probably happening in your body. Here’s what’s probably going to happen next.
Trying very hard not to make it just fear-based, but to make sure it’s a very informed decision that someone is making of whether they want to choose recovery or whether they want to continue those behaviours, and recognising that there’s a choice there, but it’s not like it’s all choice. There’s a very strong illness that’s pushing somebody down the path of trying to cover up the seriousness of the likely consequences of the eating disorder.
Chris Sandel: Definitely. Just piggybacking on what you said there, in terms of the symptoms, for so many people it can feel like this riddle, like “I just don’t understand why this is all occurring.” And it’s actually pretty straightforward; your body’s just not getting the amount of energy and the amount of nutrients that it needs, and that has an impact on every system, every organ in the body. So yeah, there are all these different things that are occurring and they make sense through the lens of when your body doesn’t get what it needs, it has to turn things off. It needs to turn things down, and the symptoms are the end result of that.
Dr Brad Smith: Right. Eating disorders are similar to many other illnesses or conditions where people sometimes can channel those close calls into some form of really good motivation for the recovery. We don’t wish that on anyone, but we also don’t want to cover it up when it’s happening.
At least my style is to try to be very informative for people, but if we’re seeing something subtle going on in their labs, it’s like, maybe it’s still not a big deal, but these are the early signs of things going wrong in this part of your body. Or if we’re seeing something on their EKG that maybe a cardiologist may not want them to do any sort of intervention right now, but it’s a sign that we shouldn’t be seeing in somebody who’s 25 and otherwise healthy – we don’t see those things on their EKG.
So it’s about trying to be a good healthcare advisor as well, because not all the specialists, as great as they are and as knowledgeable as they are in their field – circling back to what I said earlier, there’s not a lot of training for medical professionals in eating disorder work. So they may not be seeing it through that lens and they may be in some cases overzealous in terms of what they might advise for intervention, in some cases not as worried as they might need to be because they’re not factoring in, or maybe they’re not aware of what’s going on with the eating disorder for that individual.
00:37:54
Chris Sandel: Yeah. There’s a lot of diet culture that then makes its way into doctors. The amount of times that I’ve had clients who are really struggling where they’ve had bone density scans that are showing they’ve got osteopenia, where they’re not getting their period, where there’s all of these things that are going on for this individual, and yet they’re being told, “It’s great, you should really keep up the level of exercise that you’re doing, it’s clearly helping” or “I wish I could eat as healthy as you” and really reinforcing so many of these behaviours. Rather than seeing them as “This is a real big problem and it’s creating a lot of the things we’re seeing, there’s a lot of more head-scratching, like “I don’t understand why you’re not getting your period or why you’ve got osteopenia at age 30. It just doesn’t make sense.”
Dr Brad Smith: We talked earlier about not wanting to use fear as a motivating factor or the main motivating factor for people, but I think those are the types of messages that help medical providers who may not have had a lot of eating disorder training: just continuing the message about the severity, the mortality, the morbidity. That usually makes other doctors take notice.
Even people that are really sensitive and want to be aware of what’s going on in individuals with eating disorders, again, there’s a lack of formal training for most people who go through different residency programmes, whether that’s primary care or sub-specialty programmes. For a variety of reasons and hypotheses, it hasn’t really cemented itself into a lot of training for medical professionals the way that I hope it will be in the future.
Chris Sandel: We are on the same page with that. For how common eating disorders are, and especially if we then branch out and look at disordered eating that might not get an official diagnosis but is still creating a lot of problems in people’s lives, it’s a huge percentage of the population. And it outstrips a lot of the other things that we are very concerned about and gets a huge amount of attention and huge amounts of training within doctors’ training. I do hope that in the not-too-distant future, we are seeing that there is this really big shift of recognising how common this is, because I do think it is getting missed.
Dr Brad Smith: I think there’s a corollary with general mental health issues as well, and we see pretty good traction happening there in primary care offices, paediatricians, internal medicine, family practice offices, where there is much more awareness about general mental health issues. There is more effort, more system-based work happening to try to integrate the care for general mental health issues.
So if the eating disorder field can continue to take the cue of what’s happening there and try to infiltrate the same way – there are a number of factors I’m sure that lead to that. Part of it is general mental health or psychiatry, psychology trying to move into those settings and trying to change the narrative of how much time you’re spending on mental health issues. Those training tools have been implemented.
A lot of that, though, was probably felt by the primary care clinicians as something that they started to pull for or ask for because by default, they were asked to be helping people with their mental health issues. The general lack of psychiatry providers, at least in the United States, has meant that a lot of the prescribing for general mental health medications has been from the primary care office. So the primary care clinicians are starting to pull for more training, more information. You’re seeing that in their residency programmes and medical schools.
There’s a hope that our eating disorder field can do some of the same things and get more infiltrated into those same training centres.
Chris Sandel: I have everything crossed that that’s what starts to occur.
00:42:09
I’d love to chat about some of the overlap between eating disorders and other conditions. There’s a few that I want to go through, and I think these are probably stuff that’s treated as well at Rogers – or we can remove the word ‘probably’ from that sentence; I know that it is treated at Rogers.
The first one would be OCD and eating disorders. I’m going to start in a very general way. Tell me about the overlap between these two.
Dr Brad Smith: There are a number of ways that we have seen over the many years that individuals have been doing eating disorder work the overlap here. Part of it can be simply recognition that a lot of eating disorder symptoms and behaviours can have a lot of overlap with anxiety-based fears, anxiety-based symptoms. So it’s not too much of a stretch to think of eating disorders as having a large component of anxiety as part of it.
We see a lot of obsessive-compulsive qualities in the symptoms and behaviours of individuals with eating disorders. Probably what the classic understanding of this has been, for someone with anorexia nervosa, particularly restricting type where there are a lot of obsessive-compulsive qualities of the symptoms and behaviours. So there’s always been this understanding there’s a lot of overlap there of obsessive-compulsive qualities.
The co-occurrence rates are much higher than the general population. I think they’re around the 20% range, which is probably an underestimate of people who might have diagnosable OCD. Of course, I see a skewed version because Rogers is so well-known for OCD and severe anxiety disorders that a large portion of the individuals that come to Rogers among all the different places they could get treatment for eating disorders, many of them have severe OCD and anxiety. There’s a percentage of people that have that overlap. Both disorders / conditions can be separately diagnosed.
We have the overlap where there are a lot of obsessive-compulsive qualities to somebody’s eating disorder, and then there’s also some understanding that in many people, the OCD and anxiety predate the eating disorder. So you have this underpinning of OCD-related features going on in their eating disorder development and how it manifests or comes out from a behavioural standpoint. It’s very fascinating partly because OCD and anxiety is one of the more interesting disorders from the standpoint of having a pretty clear path of how it gets better. While there are many, many different ways of addressing OCD and severe anxiety, there’s pretty good consensus that exposure-based principles, exposure-based CBT, exposure with response prevention, is at least the foundation of what is likely to work or what we think is the best way to work with individuals with OCD and anxiety.
The more that we see those obsessive-compulsive qualities, or especially if somebody has a fully diagnosable OCD condition in addition to their eating disorder, then we start to think those treatment techniques are probably going to play a larger role or help their success compared to maybe other forms of psychotherapy or other medical interventions that we might think about.
Chris Sandel: There’s a lot that I want to say connected to this, but I guess to start with, what’s the diagnostic criteria for someone to have OCD? Do you know that off the top of your head?
Dr Brad Smith: I don’t know that I can quote the DSM 5. [laughs]
Chris Sandel: But generally?
Dr Brad Smith: It’s intrusive, obsessive thoughts or fears around things that classically are considered to be not part of the person’s values or wishes. They see these things as foreign. These obsessions, these thoughts, these fears are perceived as foreign. They’re not part of who that person is or what they want to be thinking about at the time. And then the compulsions are the acts or behaviours that someone is doing to try to neutralize or reduce those obsessive thoughts or fears. Then it becomes more about the severity, the functional impact of those two features and trying to assess if there’s full criteria being met based upon primarily those two domains.
Chris Sandel: The reason I asked that was I’d heard you talk about the criteria before on a podcast, and when I listened to it, I was like, I don’t know anyone I’ve worked with with an eating disorder who doesn’t also fall into that criteria. I think you said earlier it’s like a 20% overlap. From my perspective, I struggle to think of someone who OCD wasn’t part of their eating disorder. It feels like the two things go hand in hand because yeah, there are all these compulsive and intrusive thoughts, there are all these behaviours that someone is doing in an attempt to alleviate those symptoms and sensations and feelings, etc.
It feels like OCD is pretty much baked into an eating disorder, and I’m wondering, from your perspective, could you see that you could have one but not the other? Could you see you could have an eating disorder without OCD?
Dr Brad Smith: I think so. I was trying to not oversell it, Chris, but you’re doing a good job of selling it. [laughs]
00:47:54
A lot of the reasons why we had adopted the exposure-based principles as a main part of our treatment of eating disorder symptoms and behaviours is because of that strong overlap that you just described. When you think about the intrusive thoughts of body image, unwanted thoughts that feel like they’re foreign or somebody’s placing it there, the fears – and then fears of taking on weight or taking in calories in some circumstances where people get to a point where they feel like even if they haven’t eaten the food, if they’re just close to the food, that somehow they’re going to gain weight. These thoughts that are not based in logic, that become intrusive or repetitive.
But it probably isn’t going to show up on the most well-accepted OCD measurement tool. The Yale-Brown Obsessive-Compulsive Scale, the YBOCS, is what’s used to really try to more quantitatively see if somebody’s getting to a level of severity to diagnose OCD. But those repetitive thoughts about body image, those repetitive thoughts about “Maybe that food is going to lead to me gaining weight even though I haven’t consumed it” – probably not going to show up on the YBOCS.
That’s what we’re both saying; there’s a strong overlap of the core symptoms and beliefs that seem to occur, especially as the eating disorder gets more severe, that really feel like OCD and severe anxiety at the core of it. Can they exist separately? I was sure that they can, and I think that they do, but there’s definitely this big overlap that happens.
That’s, again, why we adopted the exposure-based principles, the ERPs. One of the main treatment philosophies for the eating disorder symptoms and behaviours, even if somebody doesn’t have a separate diagnosis of OCD and anxiety because of all the things you mentioned, these OCD-like features as it relates to the eating disorder symptoms have been so pervasive. I share with people if they come in and they have tried other treatment approaches before, I don’t know if I have the evidence or the literature to say that this approach is better than other approaches. We don’t have that way to say that. But it is probably going to be different than what you’ve done before. If we’re adopting a high focus on exposure-based principles, it’s going to feel different than other approaches you’ve done.
So if you’ve tried four or five approaches that feel very similar, at the very least this is something different. There’s still going to be a lot of core principles that will be the same around what’s happening with nutrition, what’s happening with work on mood, etc., but when it comes to those exposure-based principles and the work you do there, it will feel very different than other forms of therapy.
Chris Sandel: I very much adopt the idea that eating disorders are anxiety disorders and very much see them through that lens. What I’m working on, always, is around exposure, because I think that is the way that someone overcomes the eating disorder. That’s the way that someone does the nutritional rehabilitation that they need to do. That’s the way someone learns the coping skills that they’ll use well after the eating disorder is gone to be able to have uncomfortable thoughts or feelings show up and be able to create room for those things or allow them to be there and not be hooked by those thoughts.
So yeah, from my perspective, this isn’t just a great way of helping someone recover from an eating disorder; this is the training ground for helping someone to truly have more resilience, to be able to deal with the challenges of being a human being and all the stuff that life will inevitably throw at one another.
Dr Brad Smith: I agree. That’s what really hooked me on it as well, has been the resilience component of it. I was doing a fair amount of reading and even talking with people about resilience factors, and then as a system, we started to look at bringing in this exposure-based approach – which, as you indicated, very much felt like this is a lot of what different disciplines are doing already.
We may not be tracking it, we may not be putting it on paper to help make sense of it the way that you do when you start adopting exposure-based CBT, but once you start doing that and can speak the same language as a team, then it just seemed to have even more power and success because everybody was on board, everybody knew the ways to adopt it without enabling people or overaccommodating the continuation of the anxiety or the fear-based behaviours.
I totally agree; it was something I was seeing happen already. Especially dietitians were already doing a lot of that work in terms of what are the safe foods, what are the fear foods, and how do we get there? But maybe not tracking it quite as closely as they do with the full immersion of the exposure-based ideas.
00:53:19
Chris Sandel: I definitely want to get into the exposure piece. There’s two extra co-occurring conditions I’d like to ask about. We’ve talked about OCD, we talked about anxiety and putting them pretty much in the same category. I want to just add something that I’ve definitely talked about and I’ve heard you talk about on podcasts as well; for most people, this predates the eating disorder. The person who typically ends up with an eating disorder, or for many people who end up with an eating disorder, their baseline anxiety was higher than the population average.
And when they got the eating disorder, after the honeymoon period of the anxiety feeling like it’s coming down from doing these behaviours, the anxiety was very high, and then once you get over the eating disorder, you’re going to have higher anxiety than the average person. I think there’s this misunderstanding sometimes of “I’ll do recovery and then all the anxiety will go away.” It’s like, no, it won’t. If this was there before, it’s going to be there afterwards, and what you will learn is ways of being able to cope with that, ways of being able to tolerate that, ways of being able to deal with that in a constructive way as opposed to the eating disorder. So I just wanted to add that. Do you want to add anything?
Dr Brad Smith: Yeah. I think it’s the very reason why those studies are important, because it’s not just about academic hair-splitting on which came first; it’s about, how do we help somebody so that they really get to a better functional place, so they really can live their true lives? And I think in some circles of our field, whether intended or not, there came this thought that seems to be fairly pervasive that when the eating disorder is all better, all these things will go away because maybe these other things felt a lot worse or they were more prominent when the eating disorder was bad.
Even as we try to understand the biology or the physiology around what’s happening when people are malnourished, we like to hope and think that now that they’re in a better nutritional state, the neurotransmitters will be in a better balance, and they’ll have the protein stores to make new neurotransmitters, so a lot of these things should get better. And some of them do, but if you already started off with a diagnosable anxiety disorder before the eating disorder, then it’s not going to get back to maybe where you’re going to function the best or do the best.
That’s where I think it became more clear as time goes on that trying to work on all the things that are adding to the person’s trouble functioning, the eating disorder might be the one that’s taking the top priority because there’s so many nutritional and medical acute issues and psychiatrically acute issues that can happen with the eating disorder is severe. But if we end up siloing the treatment, saying “We’re just going to work on the eating disorder right now; we’ll tackle the anxiety or the OCD later”, most people’s experience is similar to mine where those other things tend to just get worse when one gets better.
So if we’re not comprehensively trying to help somebody in a holistic manner and help them as a person tackle all the things that they’re dealing with, as hard as that sounds, that seems to be a better key for success than trying to silo each separate part of their mental health issues or challenges.
Chris Sandel: I totally agree with you on that. For me, the Minnesota Starvation Experiment was a really good thing that’s been this real cornerstone of so much of our understanding around eating disorders and malnutrition and all these things that happen. As part of that experiment, you saw the men really have all these mental health challenges because of that. They had higher anxiety, they had higher hypochondria, they had higher depression, they had all these things occur, and then as they got better, they disappeared. So it’s like, “Oh, okay, this is just what happens as part of recovery.”
But the thing is that with those men, we don’t know what happened prior to the eating disorder. And actually, what we do know about those men prior to the eating disorder is that they were in good, robust health where they weren’t having these conditions going on, and the reality is, for many people with an eating disorder, their anxiety didn’t start when the eating disorder started, or their OCD didn’t start when the eating disorder started. It started well before that. I think that’s an important thing to remember.
Dr Brad Smith: Right.
00:58:08
Chris Sandel: The next occurring condition I want to talk about is depression. Do you think about depression in the same way as anxiety and the same way as OCD and it’s an exposure-based thing? Or depression when it’s co-occurring with an eating disorder needs to be thought about differently?
Dr Brad Smith: I think it needs to be thought of differently, but it doesn’t necessarily mean the whole treatment approach changes categorically. Meaning we might still use exposure-based principles for eating disorder symptoms and behaviours, but what we’re doing with a lot of the rest of the time with an individual, instead of it being just more exposure-based principles for their OCD or anxiety, it might be we’re doing more other types of CBT, behavioural activation, more CBT/DBT skills, things that will help with the depression and the mood regulation, especially in those individual times with folks. So there’s a change in how the psychotherapy is being delivered based on those co-occurring issues.
But the eating disorder symptoms and behaviours themselves, likely we’d still keep using the exposure-based principles for a lot of that. It’s very individualistic. Somebody’s depression might be at a state where just from a state of melancholy or a state of not being able to do much or feeling overwhelmed with much of any activity; we may be doing a lot more on distress tolerance and behavioural activation to try to get the depression to a better place to really handle the exposure-based work.
We of course try to prioritise nutrition, as the adequate nutrition and the trajectory forward for nutritional stability is paramount. So if we’re going to be asking somebody to tap into all their reserves in terms of their willingness to tackle something, we’re going to be asking them to do that around their nutrition as the main foundation, and then maybe work on some of their other anxiety- or OCD-related symptoms at a later time and focus a lot more on their depression in the moment.
Depression has always been easier for me to get a better sense of whether somebody had it before the eating disorder got bad. As I said, anxiety disorders can fly under the radar a little bit and are not as easy for others to have diagnosed or said “This is a problem where you should get help for it.” But we might learn in retrospect if we really ask closer histories that people were having panic attacks pretty regularly or they were having severe social anxiety regularly. But they may not have ever sought treatment for it, whereas for folks who have depression co-occurring with their eating disorder, it for whatever reason seems to declare itself more readily before or after the eating disorder has started.
So I’m not as surprised about that when we discover. We usually have better awareness of that than the anxiety disorders. We have to do a little bit more digging maybe with the family, or maybe go back with the individual and find out more of their history.
01:01:17
Chris Sandel: The other thing that comes to mind connected to that – and this is something I’ve seen a lot more of, and doing a lot more reading and researching on – is the co-occurrence of neurodivergence and eating disorders. Whether that’s ADHD or autism spectrum disorders, and just how common these two things are with eating disorders.
One of the things that is very common with that is the masking that occurs. For a lot of people, they’ve been masking this for so long that often they are not even recognising that this thing has been going on. So that can be another reason why the anxiety can not be so obvious, or it can look like something different to what it is prior to the eating disorder.
Dr Brad Smith: Right. I think the continued expansion of understanding of different types of eating disorders has allowed us to start seeing more of that co-occurrence and even how something might’ve been explained by somebody’s other issues. If you take autism spectrum disorder, there may be some particular forms of ARFID that flew under the radar because we didn’t necessarily have a diagnosis of ARFID 30 years ago. So the better awareness, the better description of these disorders and better understanding of them has helped us start to parse some of this out.
I think also then, as treatment providers, as treatment centres, there has to be continued pivoting and flexibility and trying to tailor the treatment to help individuals that might not have been in our treatment centres in the past because these things were not diagnosed as an eating disorder before. The same technique of how to deliver eating disorder treatment can’t be just based on what works for anorexia and what works for bulimia. With the expansion of different diagnoses, different illnesses, then the people coming to us for treatment need different things than they might have 20 or 30 years ago.
Chris Sandel: Yeah, and even within anorexia or bulimia, if someone is on the autism spectrum, what they need in their recovery can look different. I think often what was then chalked up to “That’s just the eating disorder” is like, “No, that’s not. That’s actually a really legitimate request that I have because this thing is much more overwhelming because of my neurodivergence” or “Actually, because I have demand avoidance as part of my autism, we need to tailor the way that I’m being spoken to or we’re setting goals” or whatever it may be.
So yeah, this complexity of really understanding the person in front of you and being able to collaborate on “Hey, we both have this common goal. We really want to get to a place of full recovery. You want this, I want this. How do we make this happen?” From my perspective, I’m always wanting to do it in that collaborative way. I can be blunt or I can tell someone when I’m like, “I’m not sure that’s the greatest idea” or “I think that’s actually more the eating disorder being in the driving seat”, but also autonomy and respect for someone is hugely important as part of the recovery process.
Dr Brad Smith: Practitioner’s standpoint, whether you’re a therapist or a dietitian or psychiatrist, psychologist, that’s where I think a lot of the art comes into it. We look for, we continue to try to evolve evidence-based tools and techniques, but there’s not always a readymade, evidence-based technique for the person in front of you. You might be piecing together a few different things, but it’s mostly about, as a clinician, trying to find the connection with that individual and what’s going to work for them and how your interaction might be better or worse based on how you make changes.
It’s not that we can, as clinicians, be the exact same person or the exact same delivery with each different person in front of us. It takes the awareness of the different evidence-based tools and how they might apply and which ones might be best. All of us are often faced with situations where somebody may have a nuance or may have some characteristic, or may have something that they bring to the table that’s going to make it important for us to do something more individualised with how they approach those evidence-based techniques.
Chris Sandel: Yeah. It definitely is a relationship. Just as you were talking about, just going through different clients I work with, there’s times where I use a lot more humour with one person. There’s times where I am a little more direct with one person. Or there’s times where I’m using a lot more metaphors or analogies with someone else, just because from having these conversations, you’ve started to figure out where things land and what things tend to work better. So yeah, I definitely think this is an art form as much as anything else.
01:06:26
The final co-occurring condition is substance use disorders. For me, this isn’t something that comes up very much. I don’t know why. Maybe I haven’t talked about it enough or written about it enough. But is this something that’s common that you’re seeing at Rogers? And how does that impact on the treatment?
Dr Brad Smith: Yes, it’s common in terms of – going back to different levels of care, different intensities of care, in inpatient and residential, we’re likely to see circumstances where things have gotten more severe, whether that’s because of a co-occurring OCD or depression or trauma or whether it’s because of substance use, the combination of factors has led to a more acute situation for the individual. It’s very interesting. I think, again, you go back in the early stages of the field – awareness of eating disorders and involving in treatment, there’s probably less co-occurrence of substance use disorders among individuals with anorexia nervosa compared to bulimia and binge eating. So maybe early on in the history of our field, it wasn’t as prominent in terms of the awareness of substance use as a co-occurring issue. Certainly at higher levels of care, it’s very common for the co-occurrence to be happening.
It also presents in a little bit different ways sometimes because sometimes individuals with eating disorders might start to use substances in a way to basically either manage their eating disorder or to engage in behaviours related to their eating disorder. So someone with an eating disorder might become addicted to stimulants, for example, or cocaine, but it’s not because they started out using it to get high or to get a rush. They started out to try to manage their appetite. So you’ve got a couple of factors. You have all the addiction potential and dependence potential in that substance for anyone who takes it, but then you throw in the secondary gain that someone with an eating disorder might have for “Oh, this curbs my appetite too, and I don’t have to eat for the next three days”, it’s a stronger pull to keep using the substance.
So we see the substance use presenting in a little bit different way where it wasn’t just because peer pressure or friends were doing it or to get high. It was to affect their eating disorder in some way. So then you have to approach that a little bit differently when you’re trying to work on the importance of what could be the motivating factors for recovery for that person. A lot of it might be the same, but you have to make sure you’re addressing the eating disorder pull for that substance use as well.
Chris Sandel: I guess the other piece I’m thinking about, if I’m thinking of this through the anxiety lens, is that just like the eating disorder can be a way of managing emotions or getting control or feeling safe or those kinds of things, or to avoid certain thoughts or feelings, etc., the substance use can be the same thing. It’s another way of avoidance or another way of managing, in the same way that the eating disorder can play that role.
Dr Brad Smith: That’s such an important feature there, Chris. If you take away the diagnostic names or the labels, whatever you want to call it – I try to think globally. For an individual person, how do any of us deal with distress or upset, deal with stressful situations? Broadly, there are healthier ways of dealing with distress and problems and less healthy ways or bad ways.
For some individuals, this doesn’t define their eating disorder, but their eating disorder behaviours end up serving a purpose of helping them manage distress or problems. So as we start to see somebody get better from their eating disorder symptoms and behaviours, and then they get distressed, then this is all new; “How do I cope with this?” What are they going to land on in terms of a coping technique?
And sometimes they might have replaced those eating disorder behaviours with something that’s really good for an individual or really good for them moving forward, but sometimes they’ve replaced it with some other thing. Or maybe this is where the substance use – maybe it wasn’t a big factor in the past, but it’s an easy factor to reach towards in our society. Alcohol is readily available, a lot of other substances are readily available. So “I’ve got this eating disorder managed and now this really awful thing happened to me. I’m so distressed. I haven’t really worked on how to manage the distress in a healthy way. This alcohol is pretty readily available.”
We see that shifting of distress tolerance behaviours. Sometimes it could be cutting, it could be self-injury, it could be other – even acting out behaviours. But globally, it’s about how stress gets managed, or how really impactful situations get managed. That’s where we see this popping up in people that might not have ever had a major problem before. They might’ve used substances or alcohol, but they might not have had a problem with it. So that’s another somewhat novel way that it shows up in individuals who are working on recovery from eating disorders.
Chris Sandel: Yeah, and it doesn’t even have to substances, as you talked about. It can be workaholism, it can be sex. There’s just so many different ways. This is why when I’m thinking about eating disorder recovery and the way I work on it, yes, in the beginning it’s the stuff that we think of as the very classic stuff to work on connected to the eating disorder, whether that’s their relationship with exercise, whether that’s stuff around food, whether that’s bringing in more calories – all the things that are important as part of recovery.
But it’s then looking at, how has the eating disorder tentacles got its way into all of these other facets of your life? This is again why I like this anxiety framing of eating disorders, because if you’re framing it in that way, recovery really is teaching you how to deal with when anxiety comes up or when unpleasant thoughts come up or difficult situations come up. I definitely think of recovery very much through the resilience-building lens, and if you’re doing that correctly, then you’re not just building resilience connected to food; you’re doing it in all aspects of life.
Dr Brad Smith: Right. I think of that so often in terms of, whether you’re working with somebody in individual outpatient practice or in a treatment centre, that it’s more or less like trying on a lot of different things that might resonate for someone as a new coping skill, as a new thing in their life, as a new leisure activity.
Say art therapy or art groups. It’s not just for the art group or art therapy that day; it’s that this might be something that they flourish with as a new coping technique. Or it could be a new passion or profession for the person. You just never know. It’s about continuing to offer or introduce as many new things as possible because unfortunately, I think a lot of the bad things are readily available and highly promoted in the world around us. So it takes a little bit more thought to try to keep introducing or coming up with new things for any of us to try as ways of trying to manage stress.
And I mean ‘stress’ in the broadest terms. Some of the things we’re talking about happening with people are extremely impactful events in a person’s life. It’s not just a matter of like managing your day-to-day stress. It’s about we’re all going to have losses, we’re all going to have major events in our lives, and those are the times, whether it’s an eating disorder, whether it’s a substance use problem, whether it’s depression, those are the times that those things are going to get more severe if we haven’t done a good job about finding other ways of managing the distress that happens in those circumstances.
Chris Sandel: Yeah, I totally agree with you on that.
01:14:56
I want to come back to the ERP piece that you mentioned before, the exposure and response prevention. Just so you know and for listeners to know, there are lots of different modalities that I use when I’m working with people. I already mentioned polyvagal theory. I like ACT, or acceptance and commitment therapy. I know you mentioned CBT. I think there’s probably some overlap between those two. I know that ACT is an offshoot of CBT. I’ve also heard you talk on podcasts as well about the importance of the ‘B’ part, the behaviour side, as opposed to so much of the cognitive side of CBT, and we are definitely on the same page with that. I’m very much a believer that we act our way into thinking differently, we don’t think our way into acting differently. So much of the focus is on helping people to take different actions and having that lead to different changes.
So primarily I’m using ACT and polyvagal theory. I do use some NLP. I like self-compassion work, I like motivational interviewing. But I think really ACT and polyvagal theory are the predominant ones I use. For you, outside of ERP, what are the ones that you’re predominantly using or that Rogers are predominantly using?
Dr Brad Smith: Predominantly other versions of cognitive behaviour therapy or the original cognitive behaviour therapy, which I often think of as large ‘C’, little ‘b’. But exposure-based work is more big ‘B’, little ‘c’. And then dialectical behavioural therapy skills, and then at other stages of recovery, motivational interviewing. Those are the main programmatically infused techniques. And then individual therapists may pull from various modalities depending on what’s going to work for that individual person.
01:16:48
Chris Sandel: I would love to go through ERP and what that looks like and how it can be used. Let’s imagine – I’m trying to think of a scenario we could use. Maybe you think of the scenario because you know how it’s better used. So give us a scenario of how this would be used.
Dr Brad Smith: I usually try to explain it to someone based on more classic OCD principles. I think it hits home easier, and then people can start thinking about how to apply it to eating disorder symptoms and behaviours.
I usually start with a door handle. For the viewers, I’ll say the door handle behind your shoulder, if someone could imagine that’s a public restroom door handle that someone with OCD of a contamination form of OCD would have extreme anxiety and would probably have a panic attack – and this is the individual telling us this, that they would have a panic attack if they were to touch that doorknob today.
If we’re going to describe an exposure-based approach to how to get to a point where they can manage that, we ask them to write out – and this is not, as you indicated, specific to Rogers; it’s just exposure-based principles are utilised a lot in this setting at Rogers – we would ask them to write out each step up through the point of touching a door handle that they could imagine working on as an exercise to get to that point. Because the idea is facing the fear, not letting the continued avoidance of the fear continue to snowball.
So if we ask them, “Do you think you could stand 10 feet away from it and look at the door handle?”, they might rate their anxiety. Say they’re using a 1 to 10 scale; they may say that would be maybe a level 4 of anxiety, but it would definitely be something different than my baseline. And touching the door handle is a 10. So we have our scale here. And what about if we didn’t even just look at the door handle, if you just thought about touching it? They might say that would be a 2. We go through each step, like what if you were a foot away from the door handle? That’s a 6. So we just map out a progressive sequence of activities that they can work on to try to make sure that each step is managed.
We call it challenging but manageable. For example, the first exercise that we do won’t be something that causes a panic attack. It’ll be something that causes noticeable anxiety but not a full panic attack. The idea here is that the person would then do the exercise – and this is usually with a therapist or behavioural specialist working with them at their elbow, so they have that support. We acknowledge that’s kind of an accommodation or something that might neutralize some of the anxiety. But they will go through that exercise, and the therapist or behavioural specialist will ask them to keep rating their anxiety.
We hope to see almost a bell-shaped curve; their anxiety goes up and then it comes back down with time. We ask them to just keep persisting till it comes back down to 50% or less of the peak of the anxiety, and then we repeat that. We might repeat it several times. When we get to a place where the new anxiety peak is 50% or less than the original, then we might consider that to be habituated to. We’ve had an exercise where somebody has habituated to it; we can cross that one off and start working on the next one.
The next one might be to get a foot away from the door handle, and same thing, just sit with the anxiety, rating with the behavioural specialist or therapist. You can see how this is very labour-intensive. Theoretically, it’s not overpowering. It’s not that hard to wrap our head around, like why it’s working or how it can work. But it takes a lot of effort on the part of the individual, and it takes a lot of good coaching and mentorship of the therapy around doing these exercises.
If you keep doing them and keep doing the repetition, eventually the person can touch the door handle without it causing a panic attack. We see this play out over and over again with things that people come in saying they could never imagine they could touch that door handle, and with these progressive techniques, which are painstaking, they’re challenging – so it’s not about sitting back and talking about the issue; it’s about doing something very active and very challenging to get to a point where something that seemed impossible is now possible.
There’s a very good place for sitting back and talking about something. There are lots of forms of therapy to do that. Just driving home the point that this is not that. This is getting in there, doing it, and it’s all hands on deck. It helps if everybody is on the same page about what we’re doing with this. In a treatment centre, that means everybody on the staff is trained up on these basic principles. It means that we invite the families in to learn about these same principles as well so that when the person goes home, their parent or loved one or spouse could help coach them through if they’re hitting something that is challenging for them at the time.
So that’s the basic principle of this progressive movement on exercises that are designed to bring out the anxiety, to have that rise and fall of the anxiety in a repetitive way so the person habituates to it, so it’s not having the same rise anymore – and it’s also building resilience, because what a person learns is that over time, with all this repetition – we might have some cases where the peak never goes down. It keeps staying up high for some reason. For some individuals on certain exposures, it just doesn’t go down. But they also learn that they’ve tolerated it. The repetition of tolerating the anxiety is a wonderful resilience tool and experience so that it’s not foreign to someone. If they start to feel that they’re at a moderate to high-moderate level of anxiety, doesn’t necessarily mean they’re going to have a panic attack. It doesn’t necessarily mean they’re going to be in an unworkable situation.
So that’s usually the way I try to explain to people who are starting this for the first time of how we’re going to move forward. A person might come up with 150 different things that they want to work on. Some of them might be related specifically to a type of food, or it could be related to a type of setting that they’re going to eat at, whether it’s a restaurant or food being brought in. It could be about eating with certain people. It could be about preparation of food. And it could be something completely unrelated to their eating disorder. It could be about a contamination-related fear or a social anxiety fear that they’ll work on.
This is the beauty of the individual format. The individual is working on creating that list with their team so that they’ve had the main part of figuring out what it is they want to work on while they’re here, and what’s going to be manageable at first, what’s going to be in that 3 to 4 level of anxiety that will be manageable. Because we don’t want to start them at a 9 or a 10; they’ll likely get flooded, sabotage the whole situation and progress. But it’s very much the individual taking ownership of what this will look like moving forward.
We of course have suggestions. Like “If you have social anxiety, here are the five or six things we’ve seen work really well. Do any of these resonate with you?” But other times people will be coming in like, “I’ve got my list. From the first session to the next session, I’ve got it all laid out.” It’s a wonderful collaboration on the treatment plan in real time.
Chris Sandel: Nice. I’ve definitely got some follow-ups connected to everything you’ve just said there.
01:24:38
One of the first things that comes to mind, if I’m thinking about this from an eating disorder recovery standpoint, I’m typically of the opinion that making bigger changes in recovery is actually easier. The reason I say that is if we’re using you’re example here, someone could say if we’re creating our list of all these different changes that I need to make, adding in an apple could feel like it’s an anxiety-provoking thing, and we could start with that. That’s where you start with adding in one solitary apple every day.
The downside from my perspective with doing that, if we start too small, is that a lot of anxiety that occurs for making that change, and from a nutritional rehabilitation standpoint, there’s not a huge amount of upside for that. And if you do that over and over and over again, you could be months down the line and yet still not getting a lot of upside for it, and where someone gets trapped with that is then there’s this feeling of “This isn’t going to work.” There’s a lot more eating disorder thoughts that are unhelpful coming up.
The way that I’m wanting to do is kind of finding that Goldilocks zone where, cool, I don’t want you to be having a panic attack, and I’m probably wanting you to do something that feels more challenging than you imagine that you’re going to be able to be completely okay with it. Otherwise what I see is six months has gone by, there hasn’t been much upside, and the person starts to feel like “This is never going to work.” How do we stay out of that? I’d love to hear your thoughts.
Dr Brad Smith: I agree that finding that middle ground is the very important piece of this. In fact, if we have somebody who’s rating things to where they’re like, “That’s not going to cause much anxiety”, we’re basically not even starting with those so that we don’t create that feeling of “I’m doing all this repetition on something that really wasn’t that anxiety-producing to begin with or it’s a small item.”
Chris Sandel: For example, an apple could feel like it’s really anxiety-provoking for someone, and I’m still going to say, even if that may be true, the upside of you doing this is minimal if anything. So if that’s at a 7, let’s pick something that’s at an 8 that’s going to be giving you more bang for your buck, that you’re going to genuinely benefit from this.
Dr Brad Smith: Certainly what I presented is pretty overly simplistic, because what we have going on in real time is real in vivo or real-life exposures happening all around the person just being brought into a treatment environment, for example. Tons of 9s and 10s all over the place. Maybe it’s a roommate, maybe it’s being away from home for the first time. All those things are a lot of different exposures. So it’s not as controlled as everything is a 3 or a 4. When we’re saying, “We’re going to work on preparing food”, for example, we’re going to take a very systematic way of doing that.
But we’re automatically asking people to take a lot of those leaps with the meal plan, because we say we’re going to be really progressive and systematic about how we do the rest of exposures, but we have to have stable nutrition moving forward at a faster pace than you might be comfortable with. So we’re going to give and take on that. Like okay, we don’t have to dive into touching the door handle for the contamination OCD tomorrow because we know that we’re basically asking you to do a lot of 8s and 9s with the meal plan, because we need the bigger bang for the buck.
And hopefully we are getting some payoff there. Like if somebody is doing those bigger challenges and they’re like “Oh, this is actually more tolerable than I thought”, then they’re ready to dive into those other exposures more readily because they’ve had some success.
The other part that was so much cleaner in what I just had described about this process is it gives the assumption that somebody is perfectly accurate in predicting what each different exercise is going to cause them, which isn’t the case. We’re all going to be prone to mis-predict what that’s going to look like. So somebody might’ve thought something would be very manageable, but it was through-the-roof kind of anxiety, so then we have to reassess, “Where do we go from here with this? How much payoff are you going to get for this?” and prioritise what’s important. We try to prioritise nutrition right away, we try to prioritise safety issues right away, and then, again, a collaboration on the important things that are impairing your functioning at home.
But I think with the food-related items especially, there’s a lot of pushing to maybe levels of discomfort that we wouldn’t necessarily push to right away with the other forms of exposure work that we feel like aren’t as imperative or don’t have as much impact on a person’s nutritional status or their safety right now.
Chris Sandel: Cool. That’s actually really helpful to know. Just to touch on some of the things you said that I’m very much in agreement with and want to highlight, one, I think so often people spend a lot of time in this ‘what if?’ place with eating disorder recovery and coming up with all of the potential things that could happen as opposed to “Let’s run the experiment and see what happens.” This is what I really love about the exposure piece, like, let’s see what happens. It could be a complete disaster, and we’ll know that. Or it could be “There was really high anticipation anxiety, and then when I did it, it wasn’t quite as bad as what I thought, and within half an hour that had really come down, and that was much quicker than I thought.”
So that recognition, as you said, that there is this curve where it goes up and then it comes down of its own accord. Or even if that doesn’t happen, “I’ve learnt that I’m able to tolerate it.” I think that’s the piece that I’m wanting to hammer home again and again when working with people: you are able and capable of being able to tolerate these things. You are having thoughts that are telling you you’re incapable of doing that, but actually you are, and the reason you may not feel like you can do this is you just haven’t practised it enough yet. You truly are going to be able to tolerate these things.
That’s why, again, getting out of the ‘what if?’ thinking and more into the action-taking is just so important.
01:30:53
The final piece I wanted to ask connected to this is can you use it with something that someone is now avoiding? For example, if the goal is taking time off exercise, how would you use ERP connected to that, considering this is then an ongoing? Is it around when the urges come up that we then practise this and we notice the urges come down, and then two hours later the urges come up and we’re using it there? Or is it done in some other way, or you just don’t use it in that setting?
Dr Brad Smith: Just to clarify, you mean with individuals who are compulsively exercising or overexercising, how might we apply those principles?
Chris Sandel: Yes. For example, often when I’m working with someone in that situation, the goal is, for example, let’s start with a week off exercise. We’re going to have a week off exercise just so that we can start to rebuild your relationship with exercise. We can get you having the energy that was used for that exercise now into being used to repair and recover. So how would you use ERP to deal with that situation?
Dr Brad Smith: It is complicated. Depends on a number of things, but yes, we do use similar principles for the exercise pieces. One of the things that complicates it is, where is somebody medically and nutritionally? If somebody’s really in a danger zone medically and nutritionally, we really are working with them on – we kind of have to do this thing that’ll feel like flooding. We just have to get to no exercise.
Chris Sandel: You just force them to do it.
Dr Brad Smith: Yeah. Other people, though, if we’re not in a major danger zone with that acutely, we might engage them in that collaboration around exercise reduction protocol so that they’re not feeling flooded by that drastic change – which is, as you might imagine, counterintuitive and also not in complete alignment with what some other settings might do. But because we’re in an inpatient unit, somebody might be allowed to do some observable form of physical activity if we’ve cleared it medically with the idea we’re going to gradually reduce that physical activity to a point where then we will want cessation, and they’ll collaborate with us on this. It’s important to get to a point of cessation so we can rebuild this activity in a way that will be in alignment with your goals and values.
Then as we start to rebuild it, it’s very much those exposure-based principles. It might be we have a fitness therapist who will use those exposure-based principles of we’re designing something where we might start off with – for some individuals, it might look like a prescribed number of minutes you might be able to go on the treadmill at this pace. Other individuals, it might be you’ve gotten so ritualized with your exercise that it’s most important to try to not have so much compulsion around the exact number of minutes, so we’re going to have the therapist randomly pick the end for the session. Today it might be 4 minutes, the next day it might be 8 minutes, the next day it might be 12 minutes, but it’s not in the person’s control, so that exposure of not knowing when it’s going to end and trying to deal with the feelings and the anxiety of not having that certainty on it is part of the exercise moving forward to try to have it be more in alignment.
And we have them do a whole inventory of their goals and values as it relates to physical activity, what role that’s playing in the person’s life, and trying to get it away from the eating disorder-centred goals and more towards the full goals and values someone is talking about, whether it’s socialising with friends, whether it’s having a generally good, healthy body in terms of longevity of living – all those things would be factored into setting up a routine, or in some cases a lack of routine and more just enjoyment and spontaneity with physical activity.
So yes, we very much use the exposure-based principles on that, both in the coming down if somebody’s having trouble doing cold turkey and if it’s medically safe to do so, and then ramping back up if that’s important to that individual.
Chris Sandel: Nice. Definitely makes sense. This has been awesome. I’m really glad that we’ve been able to go through all this. As I said, I’ve never talked about ERP before, so to hear how Rogers is using it, how it can be applicable in different settings and at different stages that someone’s at, I think that’s been really helpful to hear this.
Where can people find more information either about you or about Rogers? Where do you want to point people to? I’ll put all of these in the show notes.
Dr Brad Smith: I think the website for Rogers would be the site, and we’ll put the contact information and the site at the end of this podcast. The website is the best place for information. It’ll have all the connection in terms of getting in contact with different service lines. Since Rogers is a full behavioural health treatment centre, not just for eating disorders – there may be other co-occurring issues or ones that are dealing with something else that’s not related to eating disorders – Rogers has treatment centre service lines for various mental health issues.
Chris Sandel: Perfect. I will put all that in the show notes. Thanks so much for your time today, Brad. It was really great getting to chat with you.
Dr Brad Smith: Great. Same here, Chris. Appreciate the opportunity.
Chris Sandel: So that was my conversation with Dr Brad Smith. Once I stopped recording, Brad mentioned that one of the things he didn’t say in the interview was just how good Rogers are for the multidisciplinary team that they have, and that this is really a strength of theirs in that there are all these different areas that they can be supporting someone with, and all in this one-stop shop. I don’t have any personal experience with Rogers; I don’t have any clients that I can think of who have been to Rogers. But from what Brad was saying in the interview and how he was talking about Rogers and just hearing him speak, I’m a fan of what they’re doing and the approach that they are taking.
As I said at the top, I’m taking on new clients. If this is something that you want help with and you want to stop living with an eating disorder and start having a much fuller life, then I would love to help. You can send an email to info@seven-health.com and just put ‘coaching’ in the subject line.
That is it for this week’s episode. I will catch you again next week. Until then, take care, and I’ll see you soon.
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