358: CBT For Eating Disorders, Chronic Pain, Insomnia, Depression, Diabetes and GLP-1’s with Jennifer Averyt

Chris Sandel: Hey, everyone! Welcome to Episode 358 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.

Before we get on with today’s show, I just want to say that I’m currently taking on new clients. If you’re living with an eating disorder and you want to reach a place of full recovery, then I would love to help. And I know full recovery can feel like this very far off in the distance thing or like “That’s for other people but not for me”, but I truly believe that everyone can reach a place of full recovery, and that if you do the things that are required to get there, you will get there.

So if you would like help with this and you want to reach that place, then you can send an email to info@seven-health.com and just put ‘coaching’ or ‘support’ in the subject line, or you can reach out via Instagram. It’s @sevenhealthcompany, and just send a DM and ask for support.

So, on with today’s show. Today it’s a guest interview, and my guest today is Dr Jennifer Averyt. Jennifer is a psychologist and has clinical and research experience in the areas of diabetes, sleep disorders, eating disorders, and oncology. She specialises in both cognitive behavioural therapy (CBT) and mindfulness-based treatments. She’s also the co-author of The Weight Inclusive CBT Workbook for Eating Disorders. Jennifer enjoys working with clients to help them reach their health-related goals, whether that involves improving sleep, better managing a chronic health condition, reducing disordered eating behaviours, or adjusting to a new diagnosis or treatment routine.

She has experience working in both primary care and specialty care medical settings and can collaborate with other health care providers to support ongoing treatment. Her goal is to provide a supportive and caring environment to help clients improve their overall health, wellbeing, and quality of life.

This is the third episode that I’ve done with the authors of The Weight-Inclusive CBT Workbook for Eating Disorders. I chatted with Dr Muhlheim in Episode 353 and then Shannon Patterson in 355. In each of those episodes, we’re talking about different things, so I highly recommend checking them out.

For this one, we talk about Jen’s background and how she got into this work. We look at the differences between working in medical setting compared to in private practice, and Jen says some very positive things about what she’s seen in the medical setting and with her colleagues, and them becoming more weight neutral and more of a Health at Every Size approach and how that’s happened over the last decade, which is very encouraging. We also then talk about GLP-1s and how this has had an impact in her work and in that setting.

We talk about diabetes and how she helps her clients, because she’s not a dietitian or a nutritionist, so talking about her role with this and how she can be helpful, and there’s lots of different areas that she helps with this. We then look at the different types of CBT. Jen has got training in lots of different types of CBT, so we look at CBT for eating disorders, for chronic pain, for depression, and for insomnia. And then we also look at the importance of community in recovery, and especially when recovering in a larger body and how important that can be.

This is a wide-ranging conversation. There’s lots of things that I talk about in this that I’ve not really covered before. Jen has such a wonderful understanding of CBT, and for so many different conditions or areas, and I think this is just a wonderful skill to have. As I talk about in the episode, I think so often, eating disorders can be missed, so someone’s coming for insomnia or someone’s coming for chronic pain, and what is then helpful is someone being able to recognise that there is an eating disorder going on and that that is going to be part of the treatment.

So without further ado, here is my conversation with Dr Jennifer Averyt.

Hey, Jen. Welcome to the show.

Jennifer Averyt: Hi, Chris. Thank you.

Chris Sandel: I’m really looking forward to chatting with you. You’re the third guest who’s coming on to talk about The Weight-Inclusive CBT Workbook, but like with the other two, it’s not going to be the same conversation again. You have your areas of specialty, and I know for you, you do CBT in a lot of different areas – insomnia, chronic pain, depression, as well as eating disorders. So I want to talk about all of those things as part of today.

00:04:47

A bit about Jennifer’s background

Just to start off with, can you give listeners a bit of background on yourself – what you do, what training you’ve done, who are the people you work with?

Jennifer Averyt: Sure. I’m a clinical health psychologist, so my training has been in clinical psychology. That’s the area my PhD was in. And then I completed more specialised training specifically in health psychology and completed the board certification process for that, which essentially means I work mainly with people who have different types of chronic health concerns. That can include sleep issues, diabetes, chronic pain. I work with individuals who have cancer, are going through cancer treatment. And eating disorders as well.

I work primarily in a major medical centre setting, and then also in private practice, and see clients with all of those concerns in both places.

Chris Sandel: I’m curious of how people end up in this work, so what drew you to this work more broadly in terms of psychology, but also then more in those specific areas and why you’re passionate about those areas?

Jennifer Averyt: It goes a ways back for me. When I was in undergraduate courses I was thinking about psychology; I had started out pre-med. I was always interested in health and biology, and at some point during college, I shifted my interest toward psychology, but I wasn’t sure what I wanted to go into. My senior year, I took a course on eating disorders and weight concerns, and it was my first time learning about eating disorders. It was my first time learning really about diabetes as well, as a part of that course. And that was my first introduction to cognitive behavioural therapy, or CBT.

So as a part of that course, we had a chance to read Christopher Fairburn’s work on CBT for eating disorders, and the original Overcoming Binge Eating workbook was part of the reading for that class. I just loved it. I thought, this treatment makes so much sense. It seemed like such a logical approach, that if you’re trying to restrict your food intake, at some point that might become really challenging and could lead to binge eating, purging, more restriction. So I really liked the model and I liked the approach.

The course was taught by a health psychologist, so I thought, “This could be an interesting area to go into.” I shifted my career plans from there, and the hope was to be able to work with people who had health concerns like diabetes who might also have eating disorder symptoms. It took a while to get there with my training, but that’s essentially a lot of what I do now, which I really enjoy.

Chris Sandel: Nice. In terms of the different buckets, is the diabetes and eating disorders the thing that takes up the most of your time in terms of the clients that you see?

Jennifer Averyt: I would say that is a lot of what I see. I also see a lot of the overlap with eating disorders and sleep concerns, and sleep concerns separately, too.

Chris Sandel: Sure. In terms of your work, you work in private practice, you work in a more medical setting; what’s your experiences with both of those? Where are things working well, where are their limitations?

Jennifer Averyt: After graduate school, when I was ready for internship, I had worked in primary care settings, endocrinology clinic settings. I really enjoyed that. I knew I wanted to keep working in some type of health care centre. I had no VA experience. So I did my internship at a VA medical centre and did my fellowship after that at an army medical centre, and that gave me a lot of exposure to challenges that come up in terms of health and eating disorders in the military and in the VA setting.

Ended up coming back to that VA and I’ve worked there since because I really enjoy that work. I think, like any other large medical setting / health care setting, there are challenges in terms of a lot of focus on weight and managing weight and a focus on weight loss that can be challenging for people who are navigating eating disorder symptoms or trying to recover from an eating disorder. There can be a lot of mixed messages and sometimes experiences of weight stigma that can further complicate the eating disorder symptoms.

On the health care setting side of things, that’s a lot of what I’ve seen over the years. In private practice, I think it’s similar; it’s just people having those experiences maybe in a less connected way with different providers they’ve seen over the years, maybe not all in one place.

00:10:04

Shifts toward weight inclusivity in the medical system

Chris Sandel: And how do you navigate that? As someone who’s working in that medical setting, who obviously has some beliefs, has written a book, that go against what is being practised or what is being taught or what is being shared with patients – how do you navigate that? Because I know for me, I’m in private practice. I do the things the way that I want to do the things, and the people that resonate with that come and see me, and the people that don’t, they don’t. But to be in a system where there is, as you say, mixed messages.

Jennifer Averyt: Yeah, it’s definitely been a challenge over the years. This would probably be a good point to say, of course, these are all my opinions, not opinions of the VA. These are all my ideas that I’m talking about, and my approaches, and don’t necessarily represent the VA in any way.

But it’s been interesting because I would say I initially was in the minority with a lot of these ideas, especially about weight-inclusive care and Health at Every Size, but there’s been growing interest in this, and I’ve seen a lot of people be more open to these ideas and thinking about how we might be able to incorporate them into different types of health care, which is really encouraging. It’s been great to have team members over the years to work with who have similar beliefs, too. I work with wonderful dietitians who also have similar approaches to eating disorder care and health care in general, I would say, in terms of that weight-inclusive approach.

Shannon Patterson and I worked together for many years, and this is where we came up with some of our ideas that we wanted to put into this new book in terms of things we’d like to change about the current process for treatment. So it’s great to have colleagues who have similar ideas and approaches, even in a big system.

I also try to provide education where I can. So I’ll do in-service presentations, I’ll do more informal consultation with people who are interested in these approaches, and try to at least plant some seeds about “This is a different approach, it may not fit with everything that we have in place right now, but it’s something to think about.”

I think people appreciate that, and a lot of people will come back to me and ask more questions and start a dialogue, which is nice and helps keep things shifting, I think, in a good direction.

Chris Sandel: Nice. It’s so nice to hear that that shift is happening. Outside of yourself being the one that is proselytizing and telling everyone else about this, what else is causing that shift? What have you seen? Have people said “I read this book” or “I heard this person talk” or “I saw this thing with my patients”? What seems to be the shift?

Jennifer Averyt: I think as more research has come out in terms of weight loss efforts and maintaining weight loss – most recently, I know there was a pretty large review study that was published that showed intermittent fasting is not effective for weight loss long term, which I think is not surprising for a lot of us who work in this area and are familiar with the research.

But I think because that was a common thing that we’d see patients saying, “Hey, my doctor recommended this to me; what do you think? Could this be a bad idea with my eating disorder symptoms?” and having those conversations, I think having more research come out about some of the challenges with these different types of intentional weight loss interventions in terms of long-term outcomes and the potential for there to be harm, that’s been helpful to start these conversations.

I also think the American Medical Association, when they released a statement about the BMI not being recommended as just a single measure of health and acknowledging some of the limitations of the BMI and some of the history in terms of harm that it’s caused – I think that really helped to shift the conversation a lot, because I think many people were frustrated with that and frustrated with having to monitor that so closely when health is obviously a much bigger picture.

So I think that was definitely a big help, and I saw a lot of change in terms of how people were thinking about things when that came out. And that was I guess almost two years ago now.

Chris Sandel: It seems like Health at Every Size and anti-diet approach and that type of thing made a lot of headway in the eating disorder space. That was an easier place to get a foothold, and that’s great that that’s the case. And that shouldn’t be the only place. It shouldn’t be like, “Well, with an eating disorder that makes sense, but not in these other areas.” It’s like, no, let’s have this filter out into all areas. And it sounds like that’s what has happened.

Jennifer Averyt: Absolutely. That’s really my hope, that this becomes more of a mainstream approach in thinking about health. There are some neat programmes, like within the VA, there’s a programme called Whole Health that looks at health in terms of eight different areas that includes relationship health, your environment, your rest, how well you’re sleeping, relaxation, and stress management. So a lot beyond what people typically hear about in terms of weight concerns.

So I think that’s an example of a really nice programme that’s thinking about health as a bigger picture, and it aligns really well, actually, with Health at Every Size.

Chris Sandel: Yeah. And then also looking at the variables that are just outside of someone’s control. Like I think so many of the social determinants of health, it’s very easy to just brush over those and not recognise, hey, there’s lots of things that people are just born into a very lucky situation or very unlucky situation, and that doesn’t mean that someone doesn’t have any responsibility, but it feels like it’s either “people don’t take care at all” or “it’s all just up to circumstance.” It’s like, there’s some of both, and a lot of it is just down to the social determinants of health.

Jennifer Averyt: Yeah, absolutely. And I think that’s been a neglected area in the past, and there are a lot more conversations about that now. Thinking about how to support people with some of those areas of the social determinants of health, that comes up a lot with sleep concerns, too. When we think about shift work and differences in who’s needing to do night shifts versus day shifts and how that impacts sleep. So yeah, a lot of interesting work, I think, incorporating that into general health care, too, not just eating disorder treatment, as you said.

Chris Sandel: I know we’re talking glowingly about how people are starting to think about these things in wonderful ways, and then there’s the massive snafu of GLP-1s, which is then pushing everything back in a different direction.

Jennifer Averyt: [laughs] Yes.

00:17:43

How GLP-1s are impacting Jennifer’s work

Chris Sandel: Again, especially because you’re working more in this medical setting, what are you seeing with GLP-1s, and how’s that interacting with the work that you’re doing?

Jennifer Averyt: This has been really interesting for me to see, because I mentioned I started out – a lot of my training early on in graduate school was in endocrinology clinics. That was around the time that GLP-1s were first being used for diabetes management. Byetta, Victoza were just coming out when I was working in those settings.

The way that those medications were being discussed was so different than what I see now, 20 years later. At that point, it was more a conversation about “This is a great tool to help manage your blood sugar levels. This will provide you with another resource that could help to manage your blood sugars and help you to get closer to your goal with your A1C.” Sometimes I would hear the endocrinologist say, “You may lose some weight”, but the primary focus was always on the blood glucose management.

Now that these medications have been refocused on weight loss and remarketed for that, it’s really changed the conversation, and I’ve noticed that even for people with diabetes, the focus somehow comes back to the weight loss. And obviously these can be great tools for diabetes management. There can be other health benefits. But I think when the focus keeps getting shifted back to weight loss, that can be really challenging for people. And again, not just for those with eating disorders, but in general, I think that can be frustrating for people when that becomes the focus, and sometimes a confusing message for them as well.

Chris Sandel: For sure. In terms of the dosage and the way it’s administered, it’s very different when we’re looking at it from a weight loss perspective compared to how it’s being administered from a diabetes perspective.

Jennifer Averyt: Yes, absolutely. That comes along with changes in side effects, changes in how it impacts your appetite and your eating, and I think sometimes the conversations about that may not be as in-depth as we might like.

I always think about the importance of informed consent. As a part of my role, I do a lot of pre-surgery evaluations for things, like transplant evaluations, and it’s really important to make sure people understand, of course, the risks and benefits of different procedures. Sometimes I worry that gets glossed over a little bit with the GLP-1s when they’re being used for weight loss at these higher doses.

People don’t necessarily know what to expect in terms of the potential risks of that, and that this would be something long term – because of course, all the research and the clinical recommendations so far suggest this would be something to take most likely for life. If the focus is on weight loss, that would have to be taking that long term.

And I don’t think people are always getting that information, or they’re not fully understanding that. Then that raises concerns for them when they start talking about that or thinking about, what are the implications for that long term in terms of cost, in terms of dealing with these side effects, some of the other effects that they notice in terms of loss of muscle and potential for bone loss. That starts to become more of a concern for people when they think about that long term.

Chris Sandel: For sure. When I think about people like Ragen Chastain or Virgie Tovar or people within the area talking about dieting and the harms of dieting, they always come back to, everyone has the right to do whatever they want to do. If you want to go on a diet, if you want to try and lose weight, it’s not that they’re against that. The part that they’re against is, we’re not being told the full story here.

So if we’re being told this is something that’s going to be easy or that there’s this success rate and that doesn’t actually match up to the data, then we want to just tell people what they’re getting themselves into, whether that’s through a regular diet, whether that’s through taking the GLP-1s. It’s like, you can do this, but we want to tell you all of these things upfront, and then you can make the decision of what you want to do.

I guess if we’re going from something that we’ve studied for a 60-week trial to now say, “Okay, cool, now this is a lifetime thing that you’re taking”, then the information we collected from that 60-week trial isn’t actually enough. We need to see what now happens when someone’s on this for 5 years, 10 years, 40 years, whatever it is. And obviously it takes time to do that kind of research, but that needs to start happening.

Jennifer Averyt: Yeah, absolutely. We’ve seen similar issues come up with other interventions. I always think about the lap band procedure that was promoted as “this will be a very effective surgery, very helpful long term” – and it is not as permanent as other types of bariatric surgery, but it is a pretty significant change. And now those surgeries aren’t even recommended anymore, because once the long-term research came out with people over 10 years since the surgery, there were more complications. It wasn’t as successful as they originally thought it would be. So that’s not even recommended anymore.

So that’s a concern in terms of, if we don’t have that long-term research, as you said, how do we really know how this would play out long term for someone? And not just over two years, but if this is for life, how will this impact someone 10 years from now, 15 years from now, 20 years from now?

Chris Sandel: Yeah. I can’t categorically 100% say what direction that will go, but there’s been lots of other medications of a similar ilk that, once we get this in people’s hands long enough, we realise, “Oh, okay, this thing causes those heart conditions; we shouldn’t be doing that” or “This thing causes this other problem and we shouldn’t be doing that.” So yes, my prediction is that at some point, we’re going to knock up against something like that.

And I was a little concerned earlier on that maybe we’re not, maybe it’s going to be too vague to be able to have something that makes it “Okay, yes, now we need to pull this thing or we need to do something different in terms of regulation.” And the more I see stuff coming out – and I probably shouldn’t be saying this with a smirk, but it was just like, the writing’s on the wall, at least from my perspective. At some point in the not-too-distant future, I think this will go the same way as fen-phen or as other things of a similar ilk.

Jennifer Averyt: Yes, I agree. It’s interesting; it’s not necessarily what I want to spend a lot of my time thinking about from day to day, but I can’t help it because it’s everywhere, and patients are asking about it all the time. I was just looking through my CE credits for the last two years for my licensure renewal, and I’ve had 20 hours just on GLP-1s. I’m not a medical provider; I’m a psychologist. That’s a lot of time spent talking about these medications and learning about them.

But I think that’s how present they are in day-to-day conversations with people, and that’s how much people are concerned about them. The overall message of these presentations and trainings I’ve been to is that we should be proceeding with caution because we don’t have all the information, and there are concerns in terms of potential for malnutrition, bone loss, muscle loss, in addition to things we might not know about yet, other adverse effects that could come out later.

So yeah, it’s concerning. It’s not, again, necessarily something I want to spend a lot of time thinking about, but I feel like I need to because people have so many questions and are trying to decide, “How do I move forward with this?”

I do want to be supportive with people wherever they’re at, because sometimes there are barriers in terms of trying to seek health care for other issues that can come up. For joint replacement surgery, for example, I can understand the pressure that people feel if they’re being told “You can’t have this surgery, you can’t have this procedure, you’ll have to lose weight first.” As you said, it’s more of a conversation. “Let’s talk about what are the implications of this if you decide to go down this road”, talking about the potential risks, benefits.

Also figuring out, how can we support someone? If they decide to move forward with that, I don’t want to say, “Okay, then I can’t work with you if you decide to take this GLP-1.” I still want to provide that support, especially if they have a history of eating disorder symptoms. It just might look a little bit different. We might have to be creative about what that looks like.

Chris Sandel: Sure. It’s interesting, like you said, that you’re watching all this stuff and the take-home message is ‘proceed with caution’, because when I look out in the general population at what is going on, I don’t think it feels like ‘proceed with caution’. It feels like everywhere. So yeah, there’s a definite mismatch between those two things.

Jennifer Averyt: Yes, definitely. It seems like in a lot of ways it’s putting the cart before the horse. Like things just started before there was a plan. I saw a talk by Dr Lesley Williams, who’s at the Mayo Clinic now, and she was talking about the challenges of there’s no clinical guidelines yet for how to proceed to a maintenance dose or tapering people off. There’s just no information about that.

So even if someone does decide to take this and if they’re thinking about it long term, there’s no guidance yet for how to do that – which, on the medical side, I think is challenging for prescribers, too, to figure out, how do you set those expectations if we don’t know what that’ll look like 10 years from now?

Chris Sandel: Yes. It just feels, as you said, putting the cart before the horse. Like “We’ll figure that out en masse with what happens with the population.”

Jennifer Averyt: Yeah, right.

00:29:04

The range of eating disorders she typically works with

Chris Sandel: Coming back to eating disorders and the work that you do, what types of eating disorders are you seeing most commonly in your practice? Is it “I’m mostly with this”, or it’s across the board?

Jennifer Averyt: I would say across the board. I see and work with a lot of people who have binge eating disorder, binge eating like disorder symptoms, and a lot of people with – and I don’t love the term, but that current term being ‘atypical’ anorexia. Hopefully that’ll change someday. I know there’s a lot of work being put into maybe looking at that diagnostic criteria for anorexia and shifting that weight requirement.

But yeah, a lot of people who are referred to me, they might think they have binge eating disorder or someone else has told them they have binge eating disorder, but when we really break down what they’re doing from day to day and how they’re eating, it’s more consistent with anorexia because of the level of restriction. I think sometimes people just don’t realise how much they’re restricting, often because it’s gone along with diet culture and weight loss efforts that they’ve been encouraged to keep up.

I see a lot of that, and also a fair amount of ARFID referrals that I get with adults. That’s been something really interesting for me. It wasn’t something that I was originally trained in, and I became interested in it a little bit later in my career. But I’ve seen a lot more of that coming up, and that’s been really interesting to navigate, too, for people who potentially are being prescribed GLP-1s and having side effects, difficulties eating, and how those two issues can interact in those situations.

So those are the main people that I tend to see and work with.

Chris Sandel: Cool. In terms of the ARFID piece, when I had Lauren Muhlheim on – a number of years ago, the first time I had her on, we talked a lot about ARFID, looking at the different types and the different interventions connected to that. So if anyone is listening and is interested, I will put that in the show notes, because that was a really useful conversation.

Jennifer Averyt: That’s actually one of the reasons I got connected with Lauren Muhlheim originally, when I was seeking out more consultation and training. I knew she was an expert in the area, and that’s how we originally got connected.

00:31:51

The problem with diagnoses often being based on body size

Chris Sandel: Nice. In terms of your comment of people originally being diagnosed with binge eating disorder and then when we look at it, it’s really anorexia – I’ve said this many times on the podcast before. I’ve written about it. I think so many of the diagnoses that people receive for eating disorders is based on the size of their body.

If you’re in this size of body, it’s anorexia, binge/purge subtype. If you’re in this size of body, it’s bulimia. If you’re in this size of body, it’s binge eating disorder. It’s the exact same things that are going on, or slightly different depending on what type of thing someone’s using to purge or compensate or whatever, but the reason they get a diagnosis that they get is just based on their BMI.

Jennifer Averyt: Oh yeah, definitely. We’ve even had people tell us – they’ve been referred to our programme or been referred to me and said maybe they’ve tried to broach this conversation with a medical provider, and have been told, “Well, your weight’s too high to have that disorder” or “You’re thin, so you can’t have this disorder.” So getting very incorrect messages about what eating disorders look like.

Eating disorders are very much based on the behaviours, of course, not on someone’s appearance or body size. But that’s been a challenge even in terms of people navigating the system to get connected with care, I think, because sometimes they get that incorrect feedback when they’re seeking treatment for these concerns.

Chris Sandel: Yeah. And it’s not just “Well, it’s semantics, it’s a label, it doesn’t really matter.” The reason that this really matters so much is, one, I think there is this incorrect hierarchy of eating disorders, especially with people who have eating disorders. Anorexia is the ‘good’ type and binge eating disorder is the ‘bad’ type – both of those are in inverted commas – because of what we think about restriction being good and eating ‘too much’ being bad.

And also because that’s often how it’s dealt with. If you’re being diagnosed with anorexia, “This is the way that we deal with that”, and if you’re being diagnosed with binge eating disorder, it’s kind of like “Do dieting lite. We need to focus on why you’re doing the binges, and we need that part to stop. Have you thought about having more of these foods that fill you up?”

It’s like, no, these two people need the exact same treatment. They need help in terms of the same behaviours, the same thoughts, the same everything. You’re just thinking about them differently because they’re in a different size body.

Jennifer Averyt: Yeah. It’s so interesting, too, to see – the relief I can see in people when we start – let’s say CBT for eating disorders. If someone has been told that they have binge eating disorder and they’ve been encouraged to lose weight or diet in the past because of their body size, when we start getting into CBT-E and the encouragement is to eat more regularly and to focus on getting enough food and there’s no discussion of “You shouldn’t be eating this” or “You need to limit this” – I can see, really, there are physical signs that people are feeling more relieved as we start those conversations.

Because I think a lot of times what they’re expecting is more of that “Well, because of your body size, you need to do XYZ to restrict or to limit what you’re eating.” It’s just such a relief for them to not have that be the case, and then to understand that they’re really not eating enough, it really shifts their perspective. It helps them understand so much what’s been happening and why they’ve been experiencing the symptoms they have.

Chris Sandel: And I get that it’s probably a mix of people, so some people totally relieved, and then some people where it’s like just incredulous, “I can’t get onboard with this. How could that possibly be the case? How could I not need to eat less food? This doesn’t make sense.”

Jennifer Averyt: Yes, there are sometimes people who are sceptical. Like “This is not what I’ve been told and I’m not sure this’ll work, and this seems like so much food.” Yeah, there are those conversations too that come up.

00:36:37

How she uses CBT-E with clients

Chris Sandel: Sure. From a CBT-E perspective, what does that look like when working with eating disorders in practice? And I know that’s a very big question, but maybe where do you start from your perspective with this?

Jennifer Averyt: For me, I think one of the most helpful things about CBT – and this is in general, not just for CBT for eating disorders, but CBT for insomnia, CBT for chronic pain – I think the initial what we call psychoeducation, but basically just providing information about the symptoms that people are experiencing and what we understand about how they’re developed and how they’re maintained over time, that I think is one of the most helpful parts of the treatment.

Often people are frustrated; they might feel confused about why they’re having these symptoms. They’ve tried so many things to change this already. It feels like nothing’s working. And I think a lot of the times what they’re missing is that information about, “This is what we know about why these symptoms develop.”

Chris Sandel: Hang on, I’m going to stop you and just say, can you explain this to the audience? What is that bit of education that you give people to start with? And then you can carry on with what you were saying.

Jennifer Averyt: Sure. For eating disorders – and this is part of a model that we reworked as a part of our workbook – the root of I would say most eating disorders is this external pressure – it could be diet culture, it could be experiencing weight stigma in a medical setting, it could be pressure from family members, friends to maintain a certain weight or achieve a certain weight, and that pressure generally leads to restriction. That could be dieting, weight loss attempts, could be overexercise, other behaviours to try to change your weight or shape.

Then from that point forward, some people might develop binge eating symptoms; some people might develop binge eating and purging. For others, they may continue restricting, and that restriction can become more significant over time. Sometimes people might go back and forth between restricting and maybe having the binge eating.

A lot of times people haven’t made those connections to think about the chain of events that could’ve led up to that. We use what we call a case conceptualisation form, which is basically a map of “How did this start? How did your symptoms develop? And what might be keeping them going over time?” I think people find that so helpful to see, “Yes, this was my experience with maybe dieting or being pressured to lose weight at a younger age, and these were some of the things that influenced that, and this is what I’ve tried, and this is when my symptoms started.” They start to see how it all ties together, doing that.

Of course, you can pull in external factors, too. Emotional triggers, stress, changes in mood that can sometimes influence eating behaviours as well. But I think drawing that out – and I do like the visual of it. That’s why I like the case conceptualisation to really draw that diagram or map of how things happened and thinking of a timeline of how that developed over time. Really helps people to see why they’ve experienced the symptoms they have and how it all fits together.

Chris Sandel: Nice. I think that’s useful for people to understand. Where I see there can be a problem with this is when someone has the honeymoon phase of the eating disorder go on for a really long time and it feels like “That was actually working for me. That was when I was the fittest. That was when, man, I felt so good.” So there can be this disconnect that during this period where it felt like everything was working well, you were getting more and more into a hole and you just hadn’t realised it yet.

The amount of people who are athletes or hobby athletes who are like, “I did my best PB and then two months later, I was having all this chronic pain and then I got this chest infection followed by a urinary tract infection followed by this thing” – and it can be really hard to recognise that “What I was doing when I felt so good was actually my undoing.”

Jennifer Averyt: Yeah. I see similar examples with people in the military or the VA, where they think “My fitness test, I did the best I ever had on my fitness test and I was doing really well in training, but then shortly after that, things started to unravel.” And yeah, sometimes it’s hard to make that connection for folks.

Chris Sandel: Yeah, so being able to point that out to people. Either, one, you were not noticing and you were ignoring symptoms, or for whatever reason, your body was keeping all those balls in the air until it just couldn’t. People can have that real crashing down thing, where it wasn’t like progressively over the last two years, things got worse. It could be “It was fine, and then a month later I was bedridden and it was like I’d been hit by a bus.” It’s so scary, because it’s like “This has come out of nowhere.”

Especially for people where they’ve had an eating disorder in the past and they feel like “Oh, I recovered and then I had this new life and I’ve been doing so well, and now I’m reflecting on the last 10 years or the last 15 years, and was I actually really recovered?” It blindsides people.

Jennifer Averyt: Yeah, because sometimes when people are in it, it’s hard to see those patterns and make those connections. You’re right, I think sometimes that can be challenging if people have these positive associations with those earlier time periods. But doing that deeper exploration, you can usually find a way to pull that into that overall model.

Chris Sandel: For sure. After that, where do you go from there? What seems to be the next first step, typically? I know it’s different from person to person, but how do you normally get started then?

Jennifer Averyt: That’s one of the things I really like about CBT-E. It’s so flexible. You have these different areas you can focus on, but depending on the individual and how they’re presenting, you could start in one area – like maybe focus more on the dietary rules restriction, or for others you might want to introduce some of the more body image related topics earlier.

The nice thing about that flexibility, too, is that can be a really client-centred conversation to see, “What do you think would be most helpful? Where should we start?”

But I do think for the majority of individuals I work with, starting with of course the regular eating and making sure people are eating enough and working with a dietitian as a part of that. I’m lucky I do have, in private practice and at the VA, wonderful dietitians that I can work with. That makes such a big difference, I think, with this treatment.

Even though CBT-E was designed as a standalone treatment, personally I feel like it works so much better when you have a great dietitian you can work with at the same time to really support people with that regular eating piece and making sure they’re getting enough food. Which, again, might feel kind of scary initially for some people because they’ve been thinking they need to restrict more or they need to limit more, or if they can just restrict enough, that might help get rid of that binge eating. So it’s nice to have that support of a colleague to help people through that stage.

Chris Sandel: For sure. This is one of the things I talked about with Lauren and I really appreciate it in your book. This is where you start, like “Hey, you are likely in a weight-suppressed place, even if you’re not low on the BMI. That doesn’t really matter.” Getting people to really recognise that there’s not enough energy coming in, and that has such a knock-on effect.

00:45:55

The importance of changing behaviours before thoughts

I think often, especially with CBT – again, I talked about this with Lauren – there can be this real misunderstanding about what CBT is and a much bigger focus on the ‘C’, the cognitive thing of “I need to rephrase my thoughts and I need to think about this differently” when actually, it is really about behaviour. It is about taking different behaviours.

So talk about how you speak about this with your clients or patients. How do you get them to “Yes, there are lots of unhelpful thoughts that are here, and the behaviour piece is the thing that makes the difference”?

Jennifer Averyt: I’ll sometimes try to frame it to people that we want to try to address the behaviours first because a lot of times once you start eating more regularly and are being nourished more consistently, sometimes the thoughts start to improve on their own. Which is true; a lot of times when we get to the point where we’re focused more on the ‘C’, the cognitive piece of cognitive behavioural therapy, people have already started changing their beliefs and changing their thoughts.

They’ll maybe say, “I did think this at the beginning of treatment, but I’m starting to think about this in a different way.” Having that behavioural piece upfront and really supporting people to get the nutrition that they need and make sure they’re eating enough – I think that goes a long way to helping with other symptoms.

And if there is cognitive work that can be done, maybe related to the body image concerns, I think it makes that process much easier for people.

Chris Sandel: Yeah, for sure. I think when you’re doing the behaviours and you’re doing them consistently, one, a lot of the thoughts you had start to get disproved. “I thought this thing was going to happen, that was what my mind was telling me, and it actually hasn’t happened. So cool, I didn’t even need to do the thing around that thought that I thought I would have to. It’s just by taking the action, that changed.”

Or “I realised that I can actually have that thought be there and still take action, and that thought’s been there now for quite a number of months, and it now has a lot less power over me than it did before because I’ve seen that I can still do the things that I need to in terms of my recovery. It’s not so important because it’s like, oh yeah, it can be there. It’s fine.”

So I think that often when people think of CBT, it’s like “How do I get all these weapons in advance that I can then use when I come up against this thing?” as opposed to, as you go through the process, it will in a lot of ways, as you said, take care of itself. And what it’s not, we can then clean up when we’re at the point where it’s like, “Okay, this isn’t going to change of its own accord, and now we’ll address this explicitly.”

Jennifer Averyt: Yes, definitely.

00:49:02

How Jennifer works with clients with diabetes

Chris Sandel: Then if we move on to the diabetes piece – I know we’ve talked about this a little bit, but I know on your site, you said that you help individuals improve diabetes self-management and treat any mood-related concerns with diabetes. Tell me more. What does this look like? As you said a moment ago, you’re not a dietitian. So when you’re working with diabetes, how are you helping people with that?

Jennifer Averyt: Yes. Before I got more into the eating disorder field, I was interested in the connection with diabetes and eating disorders. But my initial training was really in working with people with diabetes, working in endocrinology clinics, providing that co-located care or integrated care. Having joint appointments with an endocrinologist, working with the clinic dietitian. So I got to learn a lot about different aspects of management and care, and also learning a lot about the stress of managing diabetes.

There’s this concept we talk about in health psychology of diabetes distress or diabetes-related distress, and that can involve emotional distress related to the diagnosis, just the stress of the practical, day-to-day management, how much time and energy goes into taking care of diabetes, relationship stress. Sometimes there can be tension that comes up with management or eating routines or medications with family members or friends. And then physician-related distress or treatment team distress if people feel like their physician doesn’t understand them or might not be able to help them with the challenges that they’re having.

Broadly, I can support people with the diabetes-related distress looking at those different categories and thinking about, are there maybe behavioural changes that can support improvements in those areas? Are there some cognitive strategies that can help, if there’s some ways of thinking about diabetes that could be contributing to people feeling stuck or they don’t know where to go next?

And then thinking about some more practical, more problem-solving approaches too, for challenges that might be coming up with communication with health care providers or communication with family members. So lots of different ways to provide support in that area.

And then we also know that people with diabetes are more likely to experience depression and anxiety, so one of the other treatment options that I have is cognitive behavioural therapy for depression or for anxiety, for specifically tailored for people with diabetes. A lot of times what that will look like is – again, I think people have this idea of CBT sometimes like “We’re going to talk about your thoughts and we’re going to change them in this direction.”

It’s really more about splitting things up. There’s a decision-making process that I like to talk people through where we think about, are these worries that you’re having, are these thoughts, realistic or are they unrealistic, or is it unclear? Do we not have all the information? And that can guide how we want to approach the worry, because for a lot of people with diabetes or other health concerns, they may have realistic concerns about what are the long-term implications of having diabetes? Do I have an increased risk of these complications?

These could be very realistic concerns, and as a therapist, it would not be helpful for me to say, “Well let’s challenge that thought. Let’s look at the evidence against that thought” because it’s realistic. It’s something that they will have to be able to cope with. So if it’s a realistic worry, then we can think about, are there action-based coping strategies that we can use to help the situation?

And if there’s not, if this is really something outside of your control, then we can teach people emotion-focused coping strategies, and that could be things like relaxation, mindfulness techniques, thinking about increasing enjoyable activities. So other behaviours that are focused on helping people cope with things that are outside of their control.

That’s the framework, and as I said, you can use it with other health conditions as well where there are realistic, significant worries that can come up that we don’t want to minimise or dismiss, but we want to give people tools to help manage those concerns.

Chris Sandel: Yeah. It’s interesting because I spend a lot of time using acceptance and commitment therapy, which I know is an offshoot of CBT. With what you described there, the way I’d often use it – and this, as I said, comes from ACT – is “Is this a helpful thought?” Meaning, “If I continue to think about this thought, is it actually helping me to have the quality of life that I want to be having? Is it helpful in terms of supporting the kinds of relationships that I want to be having? Is it helping me to have the kind of day that I want to be having?”

And the answer to that question will depend on the situation, because it could be useful when I’m doing some journalling to sit down and actually think about this thought and to spend some time and to map out, as you said, what could be some of the things that could reduce the likelihood of that happening, or what are some of the behaviours that would be helpful, etc. Or it could be “I’m about to go into a meeting and actually it’s not particularly helpful that I’m spending my time getting hooked by all these thoughts.” So then the answer becomes, “No, this is not actually helpful.” Or “I’m about to go out for a date with my partner, and that’s not what I want to be thinking about and focusing on as part of that date.”

So being able to recognise, “In this moment, this is actually not helpful for me” and then being able to use different techniques like defusion to be able to get some distance between yourself and your thought. I can see there’s some areas where it’s similar and there’s areas where it goes in a slightly different direction from CBT, but it’s the same general idea.

Jennifer Averyt: It is, yeah. And actually, that path of thinking about things that are outside of your control, the ACT techniques are perfect for that, really, because a lot of ACT is thinking about, “If I can’t change these things, what’s most important to me and how can I keep moving in that direction?” That can often be a part of the conversation. “Okay, I am worried about this and there’s nothing I can do about it right now, but I don’t want that to interfere with spending time with my family this weekend or planning this trip or being able to work on this project I’m excited about at work.”

So yeah, you can definitely pull some of that in. I think there’s a lot of combined CBT and ACT approaches these days, too, which I kind of love. I like incorporating the values assessment part of ACT. A lot of what I do in CBT – even though technically it’s not a part of CBT, I think it’s so helpful to get a sense of what’s most important to people in these different life areas and what they value the most about relationships, their work that they do, their hobbies. Because that can help even with the CBT side to see, how are these issues getting in the way of these things that are really important to you?

Chris Sandel: For sure. Values is something I use a lot with clients because even when someone’s in the depths of the eating disorder, people can generally still be able to recognise “What are my values?” They may be able to recognise “I’m not living in alignment with them, but I can recognise these are some of my values.”

The thing I always say about values is that it’s not that these things are set in stone. I tend to think of values as, especially if I’m using it in this way, let’s pick five things that are your values and that make sense to be your values with going through recovery.

“At this point, it makes sense for me to value growth” or “It makes sense for me to value integrity, so I’m going to use those as my values.” I’m going to be explicit about what it means. If I’m valuing growth, what does that mean in terms of my recovery? What does that mean in terms of my everyday life? So I can get a sense of when I’m living in alignment with that and when I’m then knocking up against a challenging moment of like, “What do I do here? What’s the right thing?”, there can be that reflection of “What would a person who values growth do in this moment?” or “What would a person who values integrity do in this moment?”

And sort of reverse-engineer the “This is how I’m making the choice in this moment because I’ve already outlined what it means to live with these values.”

Jennifer Averyt: I love that. I like what you said about they’re not set in stone, because I often tell people when we’re thinking about these values, this is a snapshot in time. This could change again in a few months, but this is just right now, what are you thinking about these areas? What’s most important to you? And it’s okay if that changes. We expect it to change. I think people feel a little bit more at ease putting some words to these ideas they’re thinking about in terms of what they value the most.

Chris Sandel: Yes. it’s temporary, and if we’re saying the most important thing at the moment is your recovery, what does it make most sense to be valuing in this moment? and we can review this in 3 months, 6 months, a year, whatever. But for right now, what would be useful for you to be able to keep coming back to, to help you make choices?

Jennifer Averyt: Yeah, I love that.

00:59:50

Valid health concerns vs unhelpful thoughts

Chris Sandel: The other thing I wanted to mention in terms of the health concern piece you talked about where people can really get into that – and I think this isn’t just for health concerns, but it can be for any thought – there can be this idea of “But it’s true.” And being able to recognise, something can be true and it can also be really paralysing if I spend all my time thinking about it. It can help me to go right back into the eating disorder’s arms if I keep thinking about this thing.

So we can recognise that might be true, and it’s not useful for you to be spending your time thinking about this. Or when you notice those thoughts coming up, we need to be doing tools / techniques so that you get some distance between them and you’re not getting into this whole rumination with them and then having that impact your behaviours.

Jennifer Averyt: Yeah, absolutely. One of my favourite techniques that can sometimes go along with that is scheduled worry time, which when I tell people about that initially they’re a little hesitant, because who wants to schedule more time to worry? They’re often coming to me because they feel like they’re worrying too much.

But I think with that strategy, it’s almost like becoming more efficient with worrying. You pick a time of day and you set a timer for let’s say 15 or 20 minutes, and that’s your limit for much time to spend thinking about this thing, worrying about it. You can do some problem-solving, and then at the end of that time period, say “Okay, I’ve thought about this for the day, I don’t need to worry about this anymore, but I can come back to it tomorrow.”

I think sometimes if people have a hard time letting go of those worries and feel like they’re spending a lot of unhelpful time thinking about it, that’s sometimes another tool that can help them feel like they can keep those worries somewhere where they can come back to them, but it’s in a much more time-limited way.

Chris Sandel: Yes, for sure. I think there can be then the feeling of “I’m worrying about this thing and I shouldn’t be worrying about this thing” and there’s all of that layered on top, where it’s like, cool, let’s dedicate this time. Do some free writing, get all of those things out. You now have them written down. There’s not the fear that “I’m going to forget them.” Great. Then we can come back to that in a week’s time, a month’s time, 6 months later. But cool, you had permission to then get that out.

The same way as if someone’s feeling angry, being able to fully express that in a healthy way, whether that’s screaming, punching a pillow, whatever it is, so I can get that out so I can then come back to “Oh okay, this is okay. That can be there and I feel totally fine with it being there.”

Jennifer Averyt: That permission piece I think is so important, because a lot of times once people feel like they have the permission to do these things, it decreases the pressure to do it. Often people find if they’re giving themselves permission to think about these emotions or process these thoughts or worries, they end up thinking about it less because they’ve been trying so hard not to do it. It has that paradoxical response, which can be really helpful.

01:03:16

CBT for depression

Chris Sandel: For sure. With the CBT for depression, I know with the CBT-E, with the eating disorder, you outlined “This is the place I always start in telling them this way of thinking about this.” I know you outlined something with the CBT-D. Was that that master piece that you do at the beginning?

Jennifer Averyt: It’s similar. I think for any of the health concerns, including diabetes, I like to map out a similar CBT model, but how our thoughts, our feelings, and our behaviours are related. But then I like to add in physiological factors because we know, especially with something like diabetes – again, there are higher rates of depression and anxiety, and there’s research to suggest at least some of that is related to some common physiological factors. Like inflammation is one proposed element that could be leading to the increased rates of depression.

So I’ll talk about how the physiology of having this medical illness can tie into this model of how our thoughts, our feelings, and our behaviours are related, and then also add in the environment as another factor outside of this model. That could be how it is to manage diabetes with family, with friends, in your workplace. How is it to seek treatment and health care? A big concern that comes up for people I work with is insurance. “Will I have insurance to keep covering these supplies? Am I going to be able to keep getting insulin if I need it?” So those external factors play a big role, too.

It’s like the original CBT model of our thoughts, our feelings, and our behaviours are related, but it’s within these other factors that can have a big influence on how we’re thinking and feeling about things. That’s how I like to approach it with the health concerns.

Chris Sandel: That makes complete sense. I use a lot of polyvagal theory as a way of explaining that, like basically the state that we are in, whether we’re in safe and social or whether we’re in fight or flight. There are lots of factors that have an impact on how we find ourselves in that state. Yes, it can be your nervous system picking up cues of safety or cues of danger. It can be when was the last time you ate? When was the last time you slept? How good was the quality of sleep? Did you have an argument with someone recently?

There’s all of these factors, some that’ll be very obvious, some that you won’t even know are having an impact on you. And depending on what state you’re in will dictate the kinds of thoughts and feelings and sensations and emotions and beliefs and perceptions that will naturally arise within you. And it sounds like the model you’re talking about is doing that, but just being a little more specific about “There are these health concerns and there are these things that have an impact on your physiology because of blood sugar”, etc.

Jennifer Averyt: Absolutely, a lot of similarities with polyvagal theory.

01:06:46

CBT for chronic pain

Chris Sandel: Talk about CBT with chronic pain. What does this then involve? How much is chronic pain within CBT seen as purely physical versus it’s something else?

Jennifer Averyt: CBT for chronic pain is a lot of similarities in that there’s so much education initially. I think this is one type of treatment where often people are a little bit more sceptical, I would say, because often people have been dealing with pain for so long, and being referred to a psychologist is maybe not top on their list of what they’re thinking of as being beneficial. Which I can understand.

Chris Sandel: And maybe they’re thinking that people don’t think that they’re telling the truth or that there’s something wrong with them that way.

Jennifer Averyt: The pain is all in their head. Which is, of course, not the way we’re thinking of it. But then if you start to present this model of CBT, there is a lot of talking about your thoughts and your feelings and how that can influence pain.

I try to take an approach of thinking about this as a part of really multi-disciplinary care. The CBT for chronic pain is just one part of this treatment for pain, and we know that with chronic pain, there can be changes in the nervous system that can sometimes contribute to that pain continuing over time, and the role of CBT is to help to provide some tools that can sometimes lessen the effect of that to allow people to participate in more active recovery in terms of working from a rehabilitation approach. So working with physical therapy to build up strength and mobility again.

I think that helps a lot with chronic pain, similar to eating disorder treatment, I would say, in that I definitely want people to think of it as a team-based approach and that this is not an alternative to their medical care for their pain; it’s a part of it. It’s a part of the overall treatment plan.

And I think that helps to get a little bit more buy-in. People feel a little bit more confident trying it out in that way. And then focusing on what we know in terms of the neuroscience of pain and providing lots of education about that and what we know about how pain can change over time – once you’ve had an acute injury and it turns into more chronic pain, the changes that we know can happen in the nervous system and how feedback loops can start to develop that can keep that pain going.

And then helping people to see, now that you understand how chronic pain can develop, here are some additional tools that might be helpful for you. A lot of it is behavioural. There’s a theme with these CBT treatments that I think many of them focus more on the ‘B’ part, the behavioural piece, than the cognitive piece, because there is so much of that behavioural part for CBT for chronic pain in terms of really in-depth relaxation training, and mindfulness training can be a part of that.

Also, in working with a team, figuring out ways to increase activity, because there can also be a lot of fear of movement that comes up with chronic pain. Helping people understand how that develops over time, why it makes sense that they might be afraid to move and afraid to re-injure themselves or make the pain worse. And at the same time, how that could be contributing to deconditioning and muscle weakness and things that could contribute to pain long term.

So helping people to feel more comfortable taking those steps in terms of behaviours to increase activity safely, and if thoughts come up that could hold them back from that, that’s when we can come in with the cognitive side of things as well.

Chris Sandel: Sure. You said we know a lot about pain from neuroscience, and there’s this education. You kind of said it, but I want to make it explicit so that we really understand how CBT thinks of chronic pain. It’s there was this acute pain, and then it in some ways just gets stuck in the system and there’s a misfiring. Like there’s not actually something here, but the system’s misfiring here, and that’s why you’re getting that feedback? Is that what’s going on?

Jennifer Averyt: Yeah, essentially. If we touch a hot stove, that’s instant pain and there’s quick feedback to the brain to tell us, “You’ve got to move your hand away.” When someone has an acute injury, there’s pain that signals you, “You might need to rest” or “You might need to not put weight on this foot” or “You need to seek treatment for this pain” – that’s how pain is helpful to us. We need pain to be able to know if something’s dangerous or unsafe, if something’s hurting us, or if we need to take a break, if we need to erst, if we need to have something treated.

But sometimes, unfortunately, when people go through that treatment for acute pain, sometimes things can get stuck in that feedback loop, so even after healing has occurred, after the injury has been treated, people can still experience that feedback from that area that there’s something wrong, there’s something that needs to be addressed.

That is something that, by shifting the attention away from that and shifting your attention to other things, you can help to decrease that incorrect feedback loop over time.

Part of what can happen with chronic pain is because pain is such a difficult type of experience to have, there’s often a lot of focus on it, and of course, the more you focus on it, the more that feedback loop is strengthened. So a big part of CBT for chronic pain is acknowledging this can happen, it’s not your fault that this has happened, and something we know can occur with pain, but how can we shift focus away from that to decrease some of that feedback loop that’s developed?

Chris Sandel: As part of that, saying the nerve isn’t actually damaged or it’s not that that’s fundamentally broken; it’s more just there’s a functional issue with it at this moment, and we’re trying to do these different behaviours that mean that that functional issue then gets resolved.

Jennifer Averyt: Yes. That’s where the team approach can be so helpful, because of course we do want to make sure that there’s nothing acute that needs to be addressed. That’s where having the medical providers to say there’s no acute injury that needs to be treated or there’s no issue that needs to be addressed, and then having the medical provider and maybe a physical therapist say there may be some weaknesses here or an imbalance or something that we can help you to strengthen in this way that could probably reduce your pain as well.

So addressing some of those functional concerns and making sure that because of the injury or whatever happened that caused the pain, there haven’t been maybe weaknesses or deconditioning or imbalances that have developed that could be a part of that that then can be addressed during treatment while they’re shifting their focus away from the sensation of pain itself.

01:15:02

Behavioural techniques for managing chronic pain

Chris Sandel: Sure. What are some of the techniques that you would be then using as part of this? From a behavioural standpoint, if you could give an example of what that could look like?

Jennifer Averyt: Sure. There is a lot of relaxation training, and that can look like a lot of different types of exercises. Usually I’ll start with some basic breathing-related relaxation exercises – things like progressive muscle relaxation, which can be really helpful if people have a lot of tension that they might not even be aware of. Visualization strategies can be helpful, especially as a distraction or shifting the attention away from pain.

I’ll sometimes use autogenic relaxation too, which is not as common, but I really love it, which is essentially relaxation exercises where you focus on feelings of warmth and heaviness in your arms and legs that a lot of people find very calming, very relaxing.

We also do a lot of work on pacing strategies. One of the challenges with chronic pain that can develop – and this is part of the feedback loop that can happen – is if people have a good day where they’re not feeling a lot of pain, a lot of times the reaction is “Let me get as much as I can done because I’m having a good day.” Which makes sense. You’re not in as much pain, you want to get things accomplished on your to-do list. But then often people feel a lot worse the next day, and they can’t be very active and they feel like they need to rest.

Over time, what happens with that pattern is people tend to do less and less over time, because they overdo it when they’re not in pain, they need to rest more, and it can limit their activity.

With pacing, we teach something called time-based pacing, where you figure out an initial estimate of “How long can I do this activity before my pain starts to act up?” and you subtract a little bit of time and you do the activity just in those small increments of time, and then you give yourself a break.

The challenge is, this can be really frustrating for people because if they’re doing something like mowing the lawn or cleaning the house, the goal is usually “I want to finish mowing the lawn. I don’t want to take a break after 10 minutes. I just want to finish it.” So there is some cognitive work that we can do with those techniques to say, “If this could help long term, can we change how you’re thinking about completing tasks and some of the benefits of taking breaks?”

Because integrating that pacing and gradually increasing the time that you can do an activity – that tends to help people be more active over time, which is one of the goals of treatment.

Chris Sandel: It’s interesting hearing you talk about this and then thinking about it alongside having an eating disorder, because then there can be times where it’s like, we are needing to take a break and we are needing to rest. I’m bringing this up for someone who’s listening to notice there are points where we are doing this thing because it’s important, and there are points that we’re doing this other thing because that’s actually now important to be working on it. It’s figuring out, what’s actually the right thing to be putting the focus on right now as part of one’s recovery?

Jennifer Averyt: Yeah, absolutely. There are some nice parallels there.

Chris Sandel: And even you talked about the autogenic ways of feeling heavier, and with helping someone to feel more relaxed or calm, etc. Again, with recovery, sometimes for me, there can be a little bit of tension there where if that happens because you did a breathing exercise or you did this thing, great. Nice little added bonus.

And that can’t be the goal. I mean, it can be maybe the goal in certain situations, like you’re talking about, but if that becomes the goal with “I can only make this change with food once I’ve got myself calm enough and relaxed enough”, that’s not going to necessarily work. The goal is actually being able to be with that discomfort and learning that you can tolerate this. Again, I’m mentioning it so that someone doesn’t think “Okay, that’s exactly what I need to do with my eating disorder recovery” because those things aren’t going to necessarily be the exact same.

Jennifer Averyt: That’s true. Yes, that’s very true. I’ll also tell people when we start those relaxation exercises, the goal is not, when you’re feeling the worst pain that you’ve experienced or when your anxiety is at 10 out of 10, that that’s when I want you to use the relaxation, because that puts so much pressure on people to have that work and be effective for them.

It’s more about, this is a part of a new routine that you’re trying out, and it’s something that you’re practicing, and it’s something to build up a skill rather than having to use it right away in situations that are stressful. Like getting ready to eat and not feeling calm. So yeah, I like that you mentioned that.

Chris Sandel: Totally. This might be a little bit of a sidebar, but have you read the book The Gift of Pain?

Jennifer Averyt: Oh, yes, yes. Excellent. It ties in with a lot of this that we’re talking about in terms of the neuroscience of pain, too.

Chris Sandel: Yeah, I remember reading it years and years ago, and for anyone who doesn’t know it, it’s about a guy who worked with leprosy when we didn’t really know a lot about it. And so much of the problems that people would see, they were trying to figure out why they would get these open sores or they would get this damage to their feet or whatever. The problem with leprosy is that it damages the nerves so that you don’t actually feel pain.

He said he would be watching these people and someone would just put their hand into a fire and pick out the food that had fallen in there because they didn’t feel the pain, so you just forget. Or you touch a stove and then you don’t recognise you’re actually touching a stove. Or with your feet, we all walk slightly different gait every single time, so you’re putting pressure on different parts of the foot. Whereas if you don’t have that sensation, you’re not making any adjustments to your foot strikes, so people can have broken bones in their feet and not actually notice it.

It was just a really fascinating book on how pain works, what happens with leprosy. Given the field that you’re in, I thought I would mention it.

Jennifer Averyt: Yeah, it’s a really good read. Some of CBT for chronic pain is reframing your relationship with pain, and I think learning about that usefulness of pain and why pain is helpful for us is beneficial with that.

01:22:34

CBT for insomnia

Chris Sandel: So let’s talk about CBT-I, for insomnia, for sleep. What’s the conceptual way that CBT frames this?

Jennifer Averyt: I’m a little biased; CBT-I is my other favourite type of CBT. One of the reasons is it’s so effective. It can help people so quickly to improve their sleep. As with the other CBT versions that I’ve talked about today, there is a lot of education initially to help people understand how sleep problems develop and things that could be maintaining sleep problems.

With CBT-I, it’s primarily for people with insomnia. You can make some modifications potentially for other sleep issues, but it’s primarily a treatment for insomnia. That’s difficulty falling asleep, difficulty staying asleep, or maybe waking up earlier than you’d like to.

The requirements for insomnia is you have enough time in bed. So it’s not that you don’t have enough time to sleep at night; you have enough opportunity to sleep, but when you get into bed, you’re not able to fall asleep or stay asleep, which can be very frustrating over time.

With CBT-I, we talk about this model of how these symptoms develop, but we use a slightly different model. It’s called the 3 Ps model, where we look at predisposing factors, precipitating factors, and perpetuating factors. Essentially, that’s things that put you at risk of developing insomnia, the initial events that start off the insomnia, and then things that keep the insomnia going over time. It’s similar to the other models, but slightly different approach.

As an example, if I’m meeting with a woman who’s developed insomnia – we know women are more at risk for developing insomnia, especially after menopause, so that would be a predisposing or risk factor. And if she noticed that her insomnia started right after a divorce, that divorce might be the precipitating factor. That was a life event that was stressful, that initially disrupted sleep and started these difficulties falling asleep, staying asleep. And then as we talk about her sleep routines, maybe we find out she’s taking a lot of naps and she’s trying to catch up on her sleep on the weekends, and we would consider those perpetuating factors, things that are keeping the insomnia going. Those perpetuating factors are the things we address in CBT-I.

I’ll often talk with people about there may be certain aspects of the risk factors we can’t control; the precipitating factors have already happened. We can’t necessarily change the events that led up to the sleep problems. But we can definitely address the factors that might be keeping your sleep problems going, and often that’s enough to bring people back to a sub-threshold level of sleep problems.

Chris Sandel: In terms of addressing those, you obviously gave the nap example as a “Hey, I want you to stop naps, I want you to have a specific bedtime routine every evening.”

Jennifer Averyt: Yeah. We think of there being really three factors that regulate sleep. One is our circadian clock, which is our internal clock that helps us know when it’s time to be awake and time to be asleep, and we really need sunlight to help keep that set. That can be a challenge for people who are doing shift work or who have to wake up really early or who live in geographic regions where it’s dark a lot during the winter. Those things can all contribute to problems with the circadian clock.

Then another factor is our sleep drive, and that’s our body’s build-up of ability to sleep. It’s very similar to our hunger drive in that when we’re awake during the day, if we don’t have a chance to eat, our hunger drive will keep building and building throughout the day. And at the end of the day, if we come home and we end up having a snack before dinner, our hunger drive might be decreased and we might not be as hungry to have dinner, but that doesn’t mean we’ve had enough food for the day. It just means that our hunger drive was temporarily decreased so we’re not going to be as hungry to have our dinner.

Very similar with sleep in that we are awake during the day and our sleep drive is building, building, building, and then at night our sleep drive decreases as we’re resting. But if we’re napping during the day or if we’re sleeping in in the morning, it interferes with our sleep drive building up enough so that even though we might feel like we need more sleep, we’re not at a point where we’re sleepy enough to fall asleep at night. So that’s another factor.

And then the third factor is what we call hyperarousal, which is elevated stress and anxiety levels. Even if you’re doing everything perfectly with your sleep, you have a consistent routine, you’re not napping during the day, you’re making sure that you’re getting exposure to sunlight in the morning – even if you’re doing all that perfectly, if your arousal level is too high at night and you’re too anxious, that can actually override your sleep drive and your circadian clock and keep you up.

And that’s a survival mechanism that we have as humans. I’ll often tell people it’s like if we think of our ancestors hunting and gathering and living in caves, at the end of the day, if you’re settling down to go to sleep and you see a mountain lion outside of the cave, you don’t want to be able to fall asleep quickly because then you’re an easy target for that mountain lion.

So that hyperarousal, it’s really great that we have that ability to override our desire to sleep, but often our modern day-to-day stressors are not mountain lions outside of our homes. It’s financial stress, worries about health, worries about family, kids, and that’s what keeps us at that higher arousal state and makes it harder to fall asleep. And that’s no longer helpful for us. That’s probably making things worse over time.

It’s not that we can turn that off. People often worry, “If I turn that off, what if something bad does happen?” I’ll describe it as it’s like turning down a dial. It’s not a light switch that’s on and off. We can just turn down that arousal level so that you can fall asleep and sleep through the night, but still be able to respond if there is an emergency, essentially.

01:29:54

Applying CBT for insomnia in eating disorder recovery

Chris Sandel: Sure. And how does this then map on – I’ve got my thoughts, but I’d love to hear yours – when you think about eating disorders? One of the common things that happens with many people, either before they enter into recovery, so when they’re in the midst of the eating disorder, or while they start recovery, they’re getting these sleep issues. How do you think about that and what’s driving that, and how you can use CBT-I with this?

Jennifer Averyt: This is kind of a new area. I think it’s really exciting that people are thinking about this and there’s more research looking at the overlap between sleep disorders and eating disorders. We know that a rough estimate is probably two-thirds of people who have eating disorder symptoms will also have some sort of sleep problems as well.

It makes sense based on what we know about eating disorders and sleep disorders like insomnia, too. I mentioned sunlight helping us to keep our circadian clock set, but eating regularly is actually another thing that helps our circadian clock to stay set. When people have irregular eating schedules, if they’re restricting, that can often disrupt the circadian clock and make it harder to fall asleep at night, sometimes make it harder to wake up during the day.

That can be worsened by other symptoms that can come up for people, like binge eating. If somebody binge eats at night, that can be very disruptive to sleep, and then they might have a hard time waking up the next day. That can interfere with their sleep drive and start to create more of this chronic pattern of sleep difficulties.

On the flipside, if people are having trouble sleeping, that can also make it more difficult to maintain a regular eating pattern. People might also, if they’re let’s say an evening person, they’re more of a night owl, and they have to work an early shift, they might not feel hungry in the morning because that doesn’t match with their natural circadian rhythm. That might make it easier to skip meals and that can contribute to the eating disorder symptoms.

So there’s lots of different ways that this can overlap. What we don’t know yet, because there hasn’t been enough research, is how can we integrate these treatments, or how can we offer both of these treatments for people who have eating disorders and insomnia?

Right now, what we’re thinking – a group of researchers that I’ve been talking with, we’re getting ready to publish a paper that’ll have information about this, but essentially there could be three approaches. You could treat the insomnia first and then the eating disorder, treat the eating disorder first and then the insomnia, or do an integrated treatment.

Chris Sandel: I’m going to go with two and three as opposed to one. [laughs]

Jennifer Averyt: Yeah. A lot of it depends on treatment availability. Not a lot of people are trained in CBT-I. It can be hard to find someone who offers the CBT for insomnia. And it’s hard to find eating disorder treatment sometimes, too. So some of that decision-making is based on availability and then what might be driving the symptoms.

So if someone is really struggling to sleep to the point where they might not be able to participate in treatment until some other sleep issues are addressed, it might make sense to at least do some of the CBT for insomnia to help them feel more ready to address the other concerns.

CBT-I can also, for some people, feel a little bit more – a good beginner treatment. It is CBT, but you’re focused a lot on sleep and behaviours, so it can feel a little bit safer as an initial start to therapy, and then once people see how helpful it is, they’re often more open to CBT for eating disorders.

But ideally, I think someday we’ll have an integrated treatment where you can do both at once. That’s something, if people have the time and they’re open to tracking their sleep and their eating behaviours, I’ll sometimes offer that myself. It’s just a little bit more work on the client side keeping track of everything, so I don’t want to overwhelm people. But I think that’s sort of where things are heading. Eventually we’ll have more of an integrated treatment to address both concerns.

01:34:42

Why it’s important to treat the eating disorder before insomnia

Chris Sandel: Nice. The reason I said I’d go with number two and number three is I feel like so much of what is driving that issue is the eating disorder. As you talked about, it is the irregular eating and not eating enough throughout the day which has an impact on the circadian rhythm.

What I also think – and this is often the way that I’ll explain it to people, and it can connect into the arousal piece that you talked about, but everyone mistakes sleep as this very passive thing. “I’m just lying on my back or lying on my side and not doing very much.”

Sleep takes a lot of energy. There’s a lot that is going on when someone is sleeping. There’s so much physical repair, there’s so much mental repair, there’s so much cleanup that’s going on in the body, and those processes all require energy. So if you’re not taking in enough energy in the day, your body’s not able to get in a mode that allows that to happen, or you do fall asleep, but at some point you in essence run out of energy, so you come back online and you get pulled out of that sleep.

So if we’re not addressing the fact that we need more energy in the system to actually do the function of sleep – because sleep is repair. So if we don’t have the thing to do that, then we’re not able to get the full eight hours or whatever is required.

This is why if someone’s trying to do all of the other things but they’re not actually bringing in enough energy, I think you’re only going to get so far.

And on top of that, I think what can happen – and I’ve seen this with lots of people, where “I slept really well throughout my eating disorder. Maybe it was a little broken, I never felt completely refreshed, but hey, I’d get into bed and I’d fall asleep and then I’d wake up eight hours later, or maybe I woke up a number of times throughout the night to go for a pee, but I’d instantly get back to sleep.” And then they start recovery, and “Man, my sleep is terrible now. I really struggle to get to sleep, or I’m waking up a lot more than I used to.”

I think if we get into the arousal piece, your body is now noticing the most important thing right now is eating, and it’s suddenly become available in a way that it wasn’t available before. If I’m comparing what’s more important, sleep or food – food. If we’ve just been living through a famine and now there’s food available, we stay awake. We get food. So the body is pushing you towards the most important thing in that moment.

Again, this is where I’m like, if you’re not doing more of the eating consistently, I’m not sure how much inroads you’re going to make in the CBT-I if you’re just doing that as a standalone.

Jennifer Averyt: Yeah, I agree. I think the second and third options probably are the best. The first option could be nice if – one way we’re thinking about it is if there’s no eating disorder treatment available and people are on a waitlist, would it be okay to start with the CBT for insomnia?

Because I think you’re absolutely right; some people may not benefit in the same way as they would when they’re eating more regularly, but it could be an option if people are waiting for treatment anyway and they have these sleep issues. Could be an option to consider. But I’m with you. Ideally, I would love to see both things happening at once because even just providing people that education about how much energy you need to sleep and that your sleep might be disrupted during eating disorder treatment and how to support people with that could be really helpful, I think.

Chris Sandel: It’s not that the CBT-I on its own couldn’t do anything. Especially if you’re looking at what are the different factors, and we’re noticing most of your eating is at the latter part of the day and now we’re starting to bring in a breakfast and bring in a lunch – the person doing it will know that they’re changing stuff to do with their eating disorder, but it’s not officially eating disorder treatment. That’s where I could see it making some inroads.

But if a lot of the other stuff from an energy standpoint is staying the same, for me, that’s the limiting factor.

Jennifer Averyt: Yeah. And I would say that’s true also for – I have similar thoughts about somebody starting CBT for depression before CBT for eating disorders. That could be really challenging before there’s enough nutrition onboard to help people, because the CBT for depression, there are some behavioural components, but it does tend to be more of that cognitive piece and thinking about different thought patterns and making adjustments. That can be really challenging if you don’t have enough energy to help your brain to think through those difficult processes.

So I think that’s another situation where sometimes it’s good to consider, if it’s available, getting people connected for that eating disorder treatment first.

Chris Sandel: For sure. And I think someone like yourself, it’s wonderful that you then have that eating disorder training because I think there could be a lot of people who just do CBT-I for insomnia or CBT-D for depression, and they’re not going to notice that someone has an eating disorder.

We have this very stereotypical view of what an eating disorder is going to be, and if someone’s going to that treatment, they’re putting up their hand and saying “Yes, I have an eating disorder.” But a lot of the time, either the person themselves isn’t even using that label to describe themselves. “Maybe I’ve got some funny stuff around food and maybe my exercise is a little bit too much” but they’re not really using that vocabulary, and it’s very easy for someone who doesn’t work in that field to be like, “Oh, no, it’s great that you’re exercising the way that you do. I wish more of the clients would exercise the way you did” and reinforcing that piece. Or the same with like “Oh, no, you eat so healthy. That’s obviously not having an impact on what’s going on.”

So someone like yourself is able to see through that and be like, “Hang on a second. That is actually a really central part of this.”

Jennifer Averyt: Yes. And that’s where I think – one, having more screening for eating disorder symptoms – I think more universal screening could be so helpful for so many ways, but also providing education for people who are offering these different types of CBT.

I just did a presentation for colleagues who offer CBT-I about this overlap with eating disorders and how to screen for these symptoms, because people aren’t necessarily going to be asking about that, but it’s so common. And that can help somebody get connected with another treatment that they need.

So I think providing education to other health care providers about what to look for, and also easy tools for screening can help a lot with that too.

Chris Sandel: Yes. I don’t think people get the prevalence of eating disorders. It’s like “We’ve got to fight the ‘obesity’ epidemic, we’ve got to stop all the diabetes”, and the rate of eating disorders is just so high.

I was speaking to a client today – she’s at college, and her and her roommate both have an eating disorder. I think there’s six of them in the house, and she’s like “There’s another roommate moving in and she also has an eating disorder.” I was like, there’s three of you now going to be living in this one house that is dealing with this. And I don’t think that that’s this strange anomaly. Yes, it’s probably higher than the average house, but I don’t think that’s the only place on campus where that is the case. I think there is a lot of this that is going on, across all age spectrums. It’s not just a thing that affects people who are in their teens and early twenties.

Jennifer Averyt: Oh yeah, definitely. I think that gets back to – we were talking about at the beginning, some of the stereotypes. People might make assumptions about whether or not someone has an eating disorder based on body size or age or other demographic factors, and we know eating disorders can affect everyone, regardless of age, body size, gender, race, ethnicity. Everyone is impacted. So helping people know the signs, know how to screen for eating disorders, I think that could help a lot to get people connected when they’re showing up for other things like sleep issues, depression, anxiety.

Chris Sandel: Yes. It should be a Step 1 “we need to rule this out”, and we need to have some clear guidance, not just – because it’s then very easy to just miss it because like “Oh, that’s not really an eating disorder. You’re just being healthy.” So to be really understanding what this really looks like in reality.

Jennifer Averyt: Yes, definitely.

01:44:27

The importance of community building in recovery

Chris Sandel: One of the areas in the book that I haven’t talked about with anyone yet that I wanted to go through with you is the importance of community building. I think this can be especially important for people who are in larger bodies, who are going through recovery. Talk about why this can be such a critical part of recovery.

Jennifer Averyt: This is something that there’s not a lot of in some of the original CBT materials, and we thought it was really important to add this in because there’s a portion of CBT-E where you think about the values again, coming back to the values. What’s most important to you? What areas of your life would you like to spend more time and energy on?

As a part of that, thinking about moving forward from the eating disorder, building a community that feels safe can be really helpful. So for a lot of people in larger bodies, because they’re inundated by diet culture and a lot of imagery on social media, in movies, television, about ideal body type, it can be helpful to intentionally seek out a community where there are other people in larger bodies who are enjoying themselves and living their lives and being happy and doing the activities that they like to do.

Some of that can happen even just on social media. We talk about cleaning up your social media feed and also diversifying it and seeking out people who you can relate to and people who may have similar body size that are talking about positive things that they’re doing and not focused on weight loss necessarily. That’s the other tricky thing, is finding people who are also taking more of a weight-neutral approach, not focused on weight loss efforts.

This doesn’t have to be – I know there’s a lot of mixed feelings about the body positivity movement. It definitely doesn’t have to be necessarily body positivity, but more neutrality and just thinking about, again, what’s most important to them and how they can engage in those activities and do those things.

So social media is a great start, but I think if there’s ways to connect locally in a community, that can be really helpful for people too. In the book we have some suggestions of how to get connected and resources for people to look at. I know here I’m in Arizona; there’s a great group locally called Fat Babies Phoenix, and they have social events, they have recommendations that they have on their website of fat-friendly resources in the area. They have things like movie nights, get-togethers.

There’s groups like that that are growing, and they’re available in more places, so we give some suggestions for how to seek that out and how to feel comfortable finding that community. That might not always be available locally depending on where people are, but there are also groups online where people can connect and talk about some of these issues, too. So that’s a nice alternative if there’s nothing available locally.

Chris Sandel: Nice. With your clients specifically, how have they found these groups in terms of what differences have they noticed by being there and participating?

Jennifer Averyt: I think it makes such a huge difference to be able to make connections and build friendships with people who you may have things in common with and may have had similar experiences in terms of some of the weight bias and weight stigma and being able to participate in groups and community where that’s not the focus. Where certainly you can relate on that level, but it’s more about just building a community where you can feel safe and interact and enjoy these activities and not necessarily have that pressure or have that concern about “How will I be treated or how will other people treat me in these situations?” It’s often a sense of relief and excitement to be able to connect in that way.

Chris Sandel: For sure. And I would also say for a lot of people it takes time to get to that place of relief and excitement. I know for a number of clients, there’s that feeling of “I don’t want to be a member of this club.” Especially if they’ve had the experience of either never being in a larger body or “I wasn’t in a larger body for a long time because of my eating disorder.” To then be back in that place, there can be a feeling of so much rejection of this, like “I don’t want that to be my reality.” And there is a grieving process to get to the point where it’s like “Okay, yeah, I do want to do this.”

Jennifer Averyt: Yes. That’s in our workbook, too. We do have a section on things like body discomfort and grieving that ideal body idea. That can often be helpful for people to work through first, to feel more comfortable, and then – it’s kind of like even using the term ‘fat’. A lot of people have wanted to reclaim that and they feel comfortable with it, but we talk about this in the book too: not everyone may be ready for that, and that’s okay. It’s more about what terminology people feel comfortable with, and if they’re not ready for that, of course that’s okay.

But even just knowing that these communities exist and they’re out there and it might be something they can connect to in the future if they’re ready for it.

Chris Sandel: Sure. I think maybe the low bar starting point is, as you say, can I follow certain people on social media, can I start to notice what’s happening over time in my body as I look at those accounts? In the beginning maybe it was disgust, maybe it was fear, maybe there were all these things, and I can notice that six months on, I have very different feelings about that and I can notice how that shifted over time.

Jennifer Averyt: Definitely. I think podcasts, too, can be great and get people thinking about things in a different way and maybe also help them feel like there’s other people who have these ideas that we’re talking about in CBT-E. So that can also be a nice resource that I’ll recommend for folks as they’re going through the process.

Chris Sandel: For sure. What have I not asked you that you wanted to make sure that we covered today, just as we’re closing this out?

Jennifer Averyt: Oh gosh. I think we’ve covered almost everything. I appreciate having a chance to talk about the sleep. As I said, that’s a newer area that’s developing, and really exciting. So I appreciate the chance to talk about that a little bit.

Chris Sandel: You’re welcome. A number of years ago, I did a two-part long-form podcast all on sleep. So for anyone listening who wants to know more, the first part was very much on the explanation around sleep, touching on some of the ideas that you talked about. I’d read Matthew Walker’s Why We Sleep book and I’d read some other stuff, so just going through that.

Jennifer Averyt: Oh yeah, that’s great.

Chris Sandel: And then the second part was more of the behavioural pieces and what can help, with the prefix of like, this is for taking into consideration people who have eating disorders. So it’s not just the general advice; it’s like, these are the things that are going to be more likely to be getting in the way, and where to start. You blocking out the red light at nighttime maybe makes a little difference, but if you haven’t had a lunch and you haven’t had a morning snack, you’re missing the forest for the trees. So let’s really start with the things that are going to be the needle movers and are going to make a difference.

So yeah, I think it’s probably three hours in total with the two shows, so if anyone wants to listen to that, I’ll put it in the show notes and you can have a listen.

Jennifer Averyt: Oh gosh, I’ll have to listen to it. Sounds great.

Chris Sandel: Where can people find you if they want to either work with you or find out more details about you? Where should they be heading?

Jennifer Averyt: My website is www.phoenixhealthpsychology.com, and I have more information about the different treatments I offer and contact information. So that’s probably the easiest place to find me.

Chris Sandel: Perfect. I will put that in the show notes, and thank you so much for coming on the show. This was a very easy, lovely chat where we got to talk about so many different things.

Jennifer Averyt: Thank you, Chris. Thanks for having me. Really appreciate it.

Chris Sandel: So that was my conversation with Dr Jennifer Averyt. If you’re looking for a therapist and you want help with things like eating disorders, diabetes, chronic pain, sleep issues, depression, then please check her out. If you also are looking for a really helpful book in terms of CBT and eating disorder recovery, then I highly recommend The Weight-Inclusive CBT Workbook for Eating Disorders.

As I mentioned at the top, I’m currently taking on new clients. If you are wanting to recover, if you want to reach a place of full recovery, then please reach out. You can send an email to info@seven-health.com or you can reach out via Instagram @sevenhealthcompany.

So that is it for this week’s episode. I’ll be back with another episode next week. Until then, take care, and I will see you soon!

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Here’s what we talk about in this podcast episode:

Intro