Episode 254: On this episode of Real Health Radio, my guest is Dr. Colleen Reichmann. We chat about Dialectical Behavioural Therapy (DBT), person-focused therapy, eating disorder recovery, motivation, harm reduction versus full recovery, the pros and cons of different levels of care, motivation and her book The Inside Scoop On Eating Disorder Recovery.
Dr. Colleen Reichmann is a licensed clinical psychologist who specialises in the treatment of eating disorders, body image issues, self-injury and trauma.
She is the founder of her private practice, Wildflower Therapy for Eating Disorders and Body Image, where she sees clients in Philadelphia.
Colleen completed her postdoctoral internship at the University Medical Centre of Princeton at Plainsboro Centre for Eating Disorders. She then worked as a postdoctoral fellow at Sheppard Pratt Centre for Eating disorders. In both of these programs, she worked across the inpatient, partial hospitalisation and IOP levels of care. She then went on to create eating disorder programming at the College of William and Mary.
Colleen is a prominent speaker and writer. She has spoken at numerous regional and national eating disorder conferences, and various universities, treatment centres and retreats.
Colleen is an advocate for Health At Every Size® and fat positivity movements and was recently named one of the top eating disorder experts in the country by a prominent eating disorder treatment centre.
And lastly, Colleen has recovered from anorexia (after years of being the patient that most therapists dreaded working with.) Her struggle with an eating disorder and subsequent recovery have led her to her passion of spreading awareness about eating disorders, and helping others to heal.
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Chris Sandel: Welcome to Episode 254 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/254.
Before we get started, I just want to mention that I’m taking on new clients. I specialise in helping clients overcome eating disorders and disordered eating, chronic dieting, body dissatisfaction and poor body image, exercise compulsion and overexercising, and also helping clients to regain their period. If you want help in any of these areas or you simply want support improving your relationship with food and body and exercise, then please get in contact. You can head over to www.seven-health.com/help, and there you can read about how I work with clients and apply for a free initial chat. The address, again, is www.seven-health.com/help, and I’ll also include that in the show notes.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist that specialises in recovery from disordered eating and eating disorders, or really just helping anyone who has a messy relationship with food and body and exercise.
Today on the show, it is a guest interview. My guest today is Dr Colleen Reichmann. Colleen is a licensed clinical psychologist who specialises in the treatment of eating disorders, body image issues, self-injury, and trauma. She is the founder of her private practice, Wildflower Therapy for Eating Disorders and Body Image, where she sees clients in Philadelphia. Colleen completed her postdoctoral internship at the University Medical Center of Princeton at Plainsboro Center for Eating Disorders. She then worked as a postdoctoral fellow at Sheppard Pratt Center for Eating Disorders. In both of these programmes, she worked across the inpatient, the partial hospitalisation, and the intensive outpatient levels of care. She then went on to create eating disorder programming at the College of William and Mary.
Colleen is a prominent speaker and writer. She’s spoken at numerous regional and national eating disorder conferences and various universities, treatment centres, and retreats. She is an advocate for Health at Every Size and fat positivity movements and was recently named one of the top eating disorder experts in the country by a prominent eating disorder treatment centre. Lastly, Colleen has recovered from anorexia after years of being the patient that most therapists dreaded working with. Her struggle with an eating disorder and subsequent recovery have led her to her passion of spreading awareness about eating disorders and helping others to heal.
I’ve been aware of Colleen for many years. I can’t remember how I first came across her work, but I used to see her posts on Instagram before I came off social media. She, along with former guest Jennifer Roland, has written a book called The Inside Scoop on Eating Disorder Recovery, so I reached out and asked her to come on the show so we could discuss it along with other topics.
As part of the episode, we chat about Colleen’s eating disorder and recovery experience; how experiences as a child shape us; the power of life pulling us towards recovery; the pros and cons of the different levels of eating disorder care; understanding amotivation and how to overcome it; the importance of person-focused therapy; harm reduction versus full recovery; dialectical behavioural therapy – what is it and how Colleen uses it with her clients; acting as if and why this is important; getting in touch with emotions and what this can tell us; and the benefits of laughter.
I really loved this conversation. Colleen is very knowledgeable but is also very easy to chat with, and if there wasn’t a time constraint, I know we could’ve gone on for hours more. I’ll be back at the end with a couple of suggestions, but for now, let’s get on with the show. Here is my conversation with Dr Colleen Reichmann.
Hey, Colleen. Welcome to the show. Thanks for taking the time to chat with me today.
Colleen Reichmann: Hi, thanks for having me.
Chris Sandel: You are a therapist and you specialise in eating disorders and have really worked in all levels of care. This is something I want to be able to chat with you about today. You’ve also written an excellent book called The Inside Scoop on Eating Disorder Recovery. I thought that could be helpful to chat about and use some of the ideas in it to have a discussion on. I also know that you have your own history with an eating disorder, so I think it would be great to chat about your experience and how this has informed the work that you do. Really, those are the three main buckets of things I want to chat about. Let’s just see where the conversation goes.
00:04:51
To start off with, do you want to give listeners a bit of background on yourself? Who you are, what you do, what training you’ve done, that kind of thing.
Colleen Reichmann: Sure. I am a clinical psychologist and I work in Philadelphia, Pennsylvania. I have a small group practice called Wildflower Therapy. We all specialise in helping folks with eating disorders, body image issues, but then also depression, anxiety. I also specialise in maternal mental health.
Let’s see. I did my training in clinical psychology and then branched off into eating disorders towards the second half of my doctorate. Went into it thinking “I definitely don’t want to work in the field of eating disorders” and then fell into it somehow, and it was kind of a passion of mine as soon as I started. I ended up doing a predoctoral internship and then a postdoctoral fellowship, both on eating disorder inpatient units. And now I’m an outpatient practitioner.
And I live right outside of Philadelphia in the suburbs with my husband and my seven-month-old and two-year-old and then our two Doodles, two dogs. [laughs]
Chris Sandel: Nice. It sounds like you have a busy life.
Colleen Reichmann: Yes, it’s a little bit chaotic but lots of fun.
00:06:18
Chris Sandel: Let’s start with you and your history. If we go back to early on, what was your household like when you were growing up concerned with food?
Colleen Reichmann: My household – it’s interesting. I grew up with a lot of privilege. I would put that out there, that there wasn’t any food scarcity and we were situated in middle class, so it was a really privileged upbringing when it comes to food. I have a mom that’s a fantastic cook and baker, and she always liked to make sure there was desserts and everything. She was into all that, and it was a nice foray into the dessert – it was just nice to have a mom that wasn’t obsessed with eliminating sugar, because I know there are so many people who have really well-intentioned parents that are really concerned about it, and then it creates harmful messaging. That wasn’t my experience.
However, we do have a really significant family history of cancer, and then just other illnesses, and both my parents have historically been interested in trying – because they’re scared, just like so many people are – to ward off illness with eating. So there was that undercurrent in the household of trying to make sure we avoid certain things because that’s connected with cancer. I think that was there from the start.
But I guess it was a balance. It wasn’t all negative messaging, but some of the messaging maybe wasn’t so helpful for me with the predisposition to an eating disorder. I also had a grandmother – my paternal grandmother had a history of anorexia and essentially had it from as long as I knew her until she passed away. One of the last things she was talking about was her weight and how to keep her weight down. So I think I had the predisposition, and some of the attitudes towards food maybe accidentally pushed that forward, if that makes sense.
Chris Sandel: Yeah, it does. Were there rules for you and rules for your mom? You talked about her baking there and how that was a lovely thing and her always providing desserts. Was it that you guys – I don’t know if you’ve got siblings – the kids got that but the adults had to do something different?
Colleen Reichmann: I don’t think so. This is the case with a lot of the people I work with, too. I think it was just here and there, less blatant and more insidious messaging. I can’t really put words to it, how it seeped in, but it wasn’t as obvious as “the kids can have it but we can’t” or “we can have it but the kids can’t.” I think it was just maybe a feeling of simmering fear that here and there different decisions were made.
I think about this with my own kids, too. It is scary, because I think they hear what you say, and that’s really important, and they see what you do when it comes to food, and they see all the little side things that happen. I can’t even put words to it, really, but there was definitely just an undercurrent of fear, I would say.
Chris Sandel: I would say that doesn’t even necessarily have to be connected to food. I’ve got a nearly five-year-old, and he is definitely highly sensitive. I would put both myself and my wife, Ali, in that same category. I can notice with him, he has this Spidey sense where he picks up exactly how we are feeling, for better or worse.
Colleen Reichmann: Oh yeah.
Chris Sandel: That then can translate into how he is at a mealtime, how he is throughout the day, or whatever, without us explicitly having to say anything. And I feel we’re doing a very good job in terms of the food side of things because of the work that I do with eating disorders and being so conscious of really wanting to create a good, healthy relationship with food. But I can notice how much just our levels of stress or fear or worry or whatever can have an impact on him.
So if, as you’re describing, there was this backdrop of fear around health and health outcomes, I can see how that would translate into having an impact on you even if you didn’t necessarily know what it was about.
Colleen Reichmann: Yeah, they pick up – it’s so frightening how much they watch. Do you ever have the experience where, I don’t know, your kid falls or something, something happens where you have a reaction even just on your face – my kids, I’ll see them looking at me. There’s a split second where they scan my face to be like, “Should I be scared? Should I be worried about this?” Sometimes it feels like such a heavy burden because I’m like, “I’ve got to do this right. I can’t create harmful messaging.” But there’s of course always opportunities to go back and repair, so I remind myself of that too.
Chris Sandel: Definitely. There are many times where I’m having conversations with Ali about “I wonder how X person would be in this situation” where he’s running along the rocks that are all slippery or something along those lines. But yes, it is very interesting to think of, if we were different in how we were within ourselves, not even necessarily in relation to him, that has such a knock-on effect.
Colleen Reichmann: Yeah, I think the work we do makes us probably all the more mindful of all this stuff, which is helpful and can create a little bit of anxiety. [laughs]
Chris Sandel: [laughs] Yes. How do you have self-awareness without neuroticism?
Colleen Reichmann: That would be my memoir title. [laughs] That’s so good.
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Chris Sandel: When do you remember food starting to change, or what are the standout moments for you as you were a kid or a tween or a teen where things started to look different with your eating?
Colleen Reichmann: I would say middle school was when food started to become somewhat of an issue for me. I just have a personality – and I write about it in the book – that I easily fall into obsession, almost. My mom tells the story – I think this is in the book – of how when I was four or something like that, she was loading the dishwasher and I was like, “Oh, you know what you could do? Put the knives in one thing and the forks in another, separate them out and be organised.” She was like, “Okay…” And then I guess later that afternoon was unloading it and I said, “I’m disappointed that you didn’t follow our system.” [laughs]
I feel like it paints the picture, it sets the backdrop for when I finally latched on to food and exercise, why. I think there’s personality and gene traits that made it easy for me to latch on to that because I was very, very uncool and unpopular in middle school and really deeply unhappy. That just became an easy focus. I also went through puberty and was really unhappy about that and how my body looked and everything.
I don’t even know how it really all tipped into beginning to be funnelled into more obsessional management of food and weight, but by the time I would say I was nearing the end of middle school, it was pretty full force. And then throughout high school, things just chugged along in a similar fashion. Then when it got to college is when I think everything popped off.
Chris Sandel: When you were in middle school or even high school, were other people concerned, whether that be friends or family? Or it was still under the radar enough that no alarm bells were going off?
Colleen Reichmann: I would say family was not super concerned because I was more private about it with my family. I had an independent streak with them. But friends, the people that I talked to about emotionally what was happening – I had one boyfriend who would repeatedly express concern. This happens for a lot of people; the unfortunate thing is, not much focus or attention happened until significant weight loss happened, and that wasn’t until college.
Chris Sandel: What changed at college? Talk about how that looked different apart from just the weight loss.
Colleen Reichmann: I have such a passion for working with college students because I found it, especially the beginning – and freshman year is probably one of the darkest years of my life – I just found it to be such a hard time of life and such a hard transition. I really struggled with it. Going away at 18. I think 18 is young. I probably sound really old saying that. [laughs] But looking back, I was young for that amount of independence.
I already had an undiagnosed eating disorder that was festering, and then I started college and was rooming with other people who had their own eating disorders or disordered attitudes towards food. And then the binge drinking. That was just constant. And the loneliness I experienced because I didn’t find a group of friends right away or feel super connected with people on my floor or anything like that. At least I had this idealized vision when I got to college, it would be like instant best friends, like your best friends for life, you’ll find them, that’s the best years of your life.
That didn’t happen, and I really struggled. I struggled to figure out how to use alcohol in any reasonable way. It was a perfect storm, I would say, and I just kind of imploded almost immediately.
Chris Sandel: Wow. It’s interesting; when I think about my own self, my own history – I haven’t had an eating disorder, but I really struggled in high school, or what would be for you guys in the US middle school and high school. And then college was actually a much better time. In Australia, you don’t really go away for college in the way that you do in the US. I was still living at home, but I then left home at age 21 and moved to the UK and have never gone back.
I actually think about the time when I moved here and that being a really great experience and me finding myself in a lot of ways. So it’s interesting to hear your experience with that. I wonder how much that’s impacted on by just the age difference of being 18 versus being 21 and versus the fact that you were already living within an eating disorder versus that not being part of my picture.
Colleen Reichmann: To me, 21 sounds much more reasonable. And I say this to my husband, Joe, all the time. I work with college students, I’ve worked in college counselling centres, so I think I’ve seen a lot of the struggle that can happen and experienced it firsthand. So I’m so worried for my kids to go away at 18 because 21 seems a lot more reasonable. I think so much happens in those years. You’re almost like a different person by that time. I wonder, if things were set up here similar to Australia or the UK, if everything would’ve happened, or if just having those years under my belt would’ve been helpful.
00:19:14
Chris Sandel: How did you then start to deal with this? When did it dawn on you that “I need help with this”, and what did that look like?
Colleen Reichmann: Throughout college, family members were approaching me and there were different interventions type situations that happened, and friends were worried. I tried various different types of treatment and care and different things. I would get better, or get better just to get people off my back, and then slip back into it. I didn’t super want it at that time. It was still really important to me to have the eating disorder and keep it around. Nothing that I tried was super successful.
But I achieved enough stability, so to speak, to graduate college. Looking back, I wonder about my university because I’m like, how did I graduate? I was really, really all over the map and just not doing well. It makes me very suspicious of them. But anyway, somehow I graduated, got into this doctoral programme that was clinical psychology, and I wanted to do research in this area. I just felt like I knew so much about eating disorders by that point, so I wanted to use it, but I wanted to do therapy with different populations. I also just didn’t think I could help. I felt kind of hopeless, so I think it’s somewhere I didn’t think it would be helpful for someone who felt somewhat hopeless in their sort of fake recovery to try to help other people.
Of course, I relapsed in graduate school very significantly. It looked a little bit different. It was very clean eating focused and exercise heavy, but frighteningly so, to the point where I had professors suggest that I leave the programme. People in my cohort suggested that as well. So I had to step back and get help at that point.
And then by that time, I had a little bit of a taste of something in life that made me feel excited, and I think that was therapy. Not with anyone who was struggling with an eating disorder, but I had started doing therapy with kids or people with anxiety, and I realised, “I really want to be able to live and do this and, I don’t know, try. I want to try. I’m so tired of being in this cycle and so tired of being the person who that’s an identity, the not-well person.”
So that was really the time when things stuck. It clicked, and I did more work when it came to myself and recovery, and I just got better in a way that I hadn’t all those other years and other times before. And then it took off from there, my life and being able to do this work and everything. Once I felt really confident in recovery, I fell into giving people therapy who were struggling with body image, and then from there, a natural extension is eating disorders. And I just loved the work so much.
Chris Sandel: Nice. It’s so interesting there where you said doing therapy helped – I thought initially you were going to talk about therapy you did on yourself, and really it was the therapy you were doing with other people and realising, I imagine, “I have value to offer. I actually like spending my time in this way. If I can get better, I get to do more of this.” In a sense, it was like “I now have something to recover for.”
Colleen Reichmann: That’s a good point. I had some therapists – I had one that I’m thinking of that really did get through to me and was kind of life-changing. But a lot of the therapy wasn’t what helped me. I mean, it was essential and it really got me started, but yeah, finding a passion in life and finding relationships that were really meaningful. I also began – when I was really young, I always wanted to be a mom, and then throughout those years in high school and college, I did not. I told everyone I didn’t want to anymore. I was really frightened of pregnancy and weight gain, obviously. I also had this idea like “I can’t have a girl. I’ll be an awful mom to a daughter.” That was really stuck in my head.
Then finally, when I got to graduate school, something shifted. I just wanted to be a mom. That dream came back. And it was all really helpful to me to have those outside passions and dreams to work for.
Chris Sandel: It’s one of the things I’ll often work on with clients; what are the things in your life that are pulling you towards recovery? What would you like to be having more of that isn’t connected to “I want to be thinner” or “I want to eat healthier” or whatever it may be, but truly is lighting up your life, or connecting this to values work, let’s look at what your values are and how they can be helpful in this regard. I do think it’s a really useful way of starting to make that shift.
Colleen Reichmann: Yeah, I totally agree. At least for myself – and yeah, I’ve seen it for so many of the clients I now work with – it’s a key factor in making some sort of – I think it helps people to get – I call it getting ‘unstuck’. It’s not going to be the thing that changes everything. It’s just something that helps you get unstuck.
00:25:39
Chris Sandel: So you were starting as a clinical psychologist and doing this throughout. One, what area did you first think you would be working in? And two, your study as a psychologist and learning more about how the mind works and personality and all of those things, how did that have an impact on your recovery?
Colleen Reichmann: I always have wanted to work with college students – although when I was in graduate school, I think some of that stemmed from my own anxiety that I looked very young, so I was like, “No-one’s going to take me seriously.” [laughs] But I was really passionate about that population and still am.
But I also did work and really, really loved working with folks with schizophrenia, actually. That was something I considered doing, like really pursuing hard after graduate school. All of it was important.
I also worked specifically focused in inpatient units with women who had very significant personality disorders, specifically borderline personality disorder, and enjoyed that too. Really loved that.
But then when I started working with people with body image and then eating disorders were an extension of that, it felt the most aligned of anything. And I think it’s because I felt like I had this empathy chip, like something in me really understood. I even heard supervisors, when I did my predoctoral internship or postdoctoral fellowship, who hadn’t struggled with an eating disorder but were working with this population say things that would suggest that they were annoyed from time to time. Like, “This tragedy is happening in my life and it’s really hard for me to listen to these patients complain about eating a cookie.”
To me, it felt like – and they were saying it obviously just in supervision and stuff, but I remember thinking, “The person’s not complaining about eating a cookie. You’re really missing – that’s not it.” And I never felt like that. I never felt the annoyance or the “I don’t get it.” I felt like I had the empathy chip and it made the work pretty seamless. Not easy, but very, very aligned. I don’t know if that answers your question, though.
Chris Sandel: It does. The other part was, how much did learning about psychology and all the different components help with your recovery or not?
Colleen Reichmann: I think it helped and perhaps it didn’t help. I think it was both. Learning more about everything that these various therapists had tried to teach me over the years – just the basics of CBT and DBT, learning them in a classroom style and then trying to help others learn them, trying to do that work myself, I think helped me actually learn and be able to then have insight into my own process and my own cognitive style. And then learning things that maybe I didn’t have therapists focus on, like family systems and things like that, helped me really deeply reflect and then bring into therapy “We learned about this; I’d like to use that, or can we use that to focus on this area?” So I think it was helpful in that way, just insight.
And then I think on the other hand – this probably happens with a lot of people in graduate school, but I think there’s a danger of becoming overly identified with mental health in general, and then if you have a niche area, and then that niche area is something that you yourself struggled with, I think it’s easy to fall into you are overly still identified with eating disorders. I’ve seen – and I think it slightly happened with me at first – people go from being really in the eating disorder themselves to fully in “I am a therapist. I am an eating disorder therapist” and it can almost become another way to stay in that eating disorder world, if that makes sense.
Chris Sandel: Yeah.
Colleen Reichmann: So I think that’s maybe how it hurt.
00:30:26
Chris Sandel: Was there fear that getting into this work could be a trigger for you? I know you said you did baby steps to getting there; initially it was body image stuff and then it went further along. But was there a point along that journey where there was a pause with you thinking, “Hang on, is this wise? Should I really be getting into this?”
Colleen Reichmann: I would say I was really fearful until I started. I think that’s maybe part of the reason subconsciously why I didn’t want to, because first I felt like “I won’t be helpful” and then when I did get strong footing in recovery, I was like “Maybe I’ll be triggered, maybe this won’t be good, maybe I won’t be able to keep my grasp on recovery.”
I feel very lucky, but it’s never felt that way for me. For whatever reason, I have never felt super triggered in any capacity, in the work on the inpatient units, at any of the levels of care. I’m not really certain why, except for – I don’t know. I’ve talked with a lot of clinicians who have struggled and felt triggered, and I really empathise with that. I think that’s probably so tough. But I feel lucky that it hasn’t felt that way for me. But yeah, I can’t put words to why except I guess I just waited until the time was right for me personally. And that was a lot of years I ended up waiting.
Chris Sandel: And maybe it was, one, just the slow pace at which you entered back into it, and two, maybe it’s just dumb luck. Some people, for whatever reason, are triggered and some people aren’t. We can all come up with the stories for why it’s so, but actually, in the same way as you talked about the genetics having an impact when you were young and then going from there, there isn’t a good explanation for why not.
Colleen Reichmann: Yeah. And if I heard me saying this when I was in high school, for instance, I would probably roll my eyes because I was always the person saying I just didn’t believe that you could get to a good place when it came to recovery. I don’t think I would believe that somebody could have an eating disorder for all those years and then work in the field and not feel super triggered a lot of the time. So I promise, if you’re rolling your eyes, that I would’ve been rolling my eyes with you. [laughs] But yeah, it shifted for me, and I really don’t feel triggered often.
And sometimes – I would say not with clients, but I have various times throughout my life here and there where I do feel triggered or have thoughts, like old thoughts. At this point, what’s been so helpful is I don’t get upset at that. I look at them with curiosity. I’ve been able to really cultivate this way of being like “That’s so fascinating that when I’m really upset, this very old thought still comes up. What is it about the mind that reaches for that?” I feel like most of our minds are wired to be like, “Oh my God, this was helpful at one point! Try this!” And I can just call that out and then move on.
Chris Sandel: Even with your comment of “my high school self would be rolling their eyes thinking I could get to this place”, I would say that’s true of basically everyone in recovery. When they think about “I’ll be able to go and sit down and have a dinner and it be a really relaxing, enjoyable experience” or “I’ll be able to go on holiday and I won’t feel the need to be checking the menu of every restaurant we’re going to go to or putting the weights in my bag” or whatever it may be, there’s this disbelief that that would ever be possible.
Because they’ve either lived with this for so long, or even if they’ve lived with it for a short amount of time, the intensity that they feel these feelings – and this then has an impact on their beliefs and perception – means that this feels as permanent as permanent will ever be. It just doesn’t feel like this is going away, and yet it does. Pretty much everyone I work with, there are moments where they are just slack-jawed and aghast, like, “I just didn’t expect this to change.”
Colleen Reichmann: Yeah. It’s so helpful, I think – and not just with eating disorders, but when we have those experiences, like, “Wow, I felt so 1000% sure that things would always be this way and things would not get better and this would not shift, and then it did” – I think that’s really powerful. The more of those experiences we get – and presumably the older we get, the more we have in these different areas – the easier it is when things are really hard in life currently to remember, “Oh my gosh, I have felt like this before, this really deep despair and this hopelessness, and I can recall that even though it felt that way, that feeling wasn’t fact. Things did change.” That’s immeasurably helpful.
Chris Sandel: Definitely. For me, I listen to lots of podcasts where it is interviewing various celebrities, whether it is actors or musicians or whatever, and I actually find them really helpful because you get to see people who in a lot of ways have everything – they have all the money, they have all the access, they have all the things that you would think on paper would make them happy, and they then talk about the anxiety they deal with or their troubles with drink and drugs or the fact that their marriage is breaking down or whatever it may be.
There’s just this real humanness to this where I can get out of my own head of like, “If I just had more money, then I would feel better about this” or “If I could just have more time off, then this would be better.” It’s not like those things aren’t true on any level, but it cuts through a lot of that kind of chatter, where I’m like, that’s not necessarily true.
Colleen Reichmann: Yeah. I find those types of podcasts and conversations really helpful to listen to, too, to remind myself.
00:37:06
Chris Sandel: When did you then become aware of and involved in the non-diet movement and Health at Every Size? How did that come up for you as part of your studies, or when did it happen?
Colleen Reichmann: It never came up in graduate school, I would say, which is I think a real loss. I’ve heard things are changing now and a little bit different, which is great, but I didn’t even hear the phrase ‘health at every size’ that first year of my predoctoral internship, and that was working on an eating disorders unit. My postdoctoral fellowship year, I also didn’t hear it there on that inpatient unit, but I stumbled into it online, I believe. I think I attended a training, an eating disorder conference, and the keynote speaker I believe – I’m blanking on her name, but she discussed Health at Every Size. I remember having a light bulb moment of like, “Wait a second, this is different than what I’m hearing, and it’s filling a lot of the holes in these theories. I can’t believe this isn’t really imperative to all eating disorder work.” It just seemed so obvious to me.
So I started seeking it out myself online and through books and also just attending conferences that were having more speakers. It was life-changing. Especially if people are learning about eating disorders in graduate school, I think it should be a natural extension of that curriculum for everyone. And I can’t believe that it wasn’t when I was in school.
Chris Sandel: I don’t know what it’s like for psychology in graduate school. I do gave a client who is studying as a dietitian, and from day one, this is part of their curriculum and their course. Again, I don’t know if that’s just the college or the university she’s at or if that’s more of a broad thing, but it’s helpful to see that there has been at least a shift that that is something that’s occurring, because that definitely wasn’t the case not that long ago.
Colleen Reichmann: That’s so nice to hear. And I have heard that – I have clients that are dietitians as well. It seems like more people in general have heard of Health at Every Size. It’s not a totally unique term to people at this point. I’ll say it and they’re like, “Yeah, I’ve heard of it.” I think that 10 years ago, that was not the case. So it’s really heartening to hear that it’s spread and people learning and maybe schools are incorporating it more, because having to already be in the eating disorders field and really doing a lot of work to seek it out seems wrong. It seems like it should be, like you said, part of things from day one.
Chris Sandel: When you were hearing about this, were you still working in inpatient? Is that right?
Colleen Reichmann: Yes, I was doing my postdoctoral fellowship, and that was on an inpatient unit.
Chris Sandel: Were you able to then start to bring some of that into that unit? How much did it feel like that unit was in alignment with what was being taught as part of Health at Every Size versus “this is going against what they’re suggesting”?
Colleen Reichmann: That was not something I was able to do. At that time – and I’m really hoping things have changed; I’m guessing they have – the messaging of the unit – there was a lot of, “We’re not trying to make you fat. We promise we won’t.” And me being – there’s a hierarchy of people, and I was lowest on that hierarchy as essentially an intern. A fellow, but not someone who’s taken seriously. Those ideas weren’t really welcomed. It was a very CBT-only-based curriculum.
I think incorporating things like Health at Every Size and sociopolitical aspects and oppression and all these other really important ideas and things that we should be talking about when we talk about people’s relationship with their bodies wasn’t something that they really allowed for. I did end up having – I left that fellowship a little bit early just because – for a few reasons, but the way they were trying to help people recover was really hard for me to get on board with by the end.
Chris Sandel: It just then became incongruent with how you wanted to help people with recovery?
Colleen Reichmann: Yes.
Chris Sandel: Where did you then go from there? I’m right in saying that you’ve done inpatient and then partial and then outpatient, is that right?
Colleen Reichmann: Yeah. Partial hospitalisation was part of the predoctoral internship, and I felt like there was more openness in that programme. I really did enjoy that one. But yeah, partial hospitalisation, inpatient, and then my fellowship was partial hospitalisation, inpatient, and intensive outpatient. I worked across those levels. Then once I left there, I ended up moving to Virginia for a little while and I started working at the College of William and Mary at their counselling centre and just creating some eating disorder and body image programming with them. Then really worked with college students, just college students for a while, and it was a wonderful experience.
00:43:38
Chris Sandel: Would it be useful to have a bit of a conversation around inpatient versus partial hospitalisation versus intensive outpatient? Considering you’ve worked at each of these levels, where there are strengths or drawbacks with each or where there’d be different preferences – is it useful to have a conversation around that?
Colleen Reichmann: Yeah. And it’s interesting because I’m kind of in a moment in life and my career where my thoughts are really evolving on all of it because I think specifically inpatient programmes are life-saving for so many people, and I’ve seen it and witnessed it and have been part of it. And they have a lot of downfalls. There are a lot for reasons that I think people should think critically before going into one of those programmes.
And then of course, outpatient, all of these different levels have areas of strength and then areas of growth edges. But I’ve just been thinking a great deal specifically about inpatient, I think because of the nature of my work. I work with people on an outpatient level, and then when they get ‘too sick’ or are really struggling, the natural step is to try to look at, how can we get you to an inpatient programme or hospitalised? I’ve seen it be so helpful, and then I’ve had people say, “That was really harmful and that did not help me at all. The things I was taught about eating, it’s changed my eating disorder rules and made it worse.”
Yeah, I don’t even know – where should we start?
Chris Sandel: I think you’ve touched on a couple of them there, of the benefits or drawbacks of inpatient. If I’m thinking about inpatient, my thoughts are I think it can be, as you said, life-saving if it is the right programme. And if it is done the right way and when someone is at a certain point where that is actually a really helpful thing for them to do. I’m thinking of a particular client in mind where I started working with her just after she came out of inpatient, and the inpatient was really helpful in being able to help her to put on some weight, and as part of doing that, it meant that her binges and purges had been reduced. It was a really helpful starting place for her for us to then do the work that we’ve been able to do.
I can also think of other clients where it was just the absolute worst thing for them because they were – in one case, after meals the person was brave enough to say, “I’m still hungry. This has not filled me up” and was told, “You’ve been given your allocated amount of food.”
Colleen Reichmann: Oh my gosh.
Chris Sandel: Which is just the worst possible thing you can say to someone in that situation, and my heart just broke when I heard that.
Colleen Reichmann: I could scream.
Chris Sandel: The other thing I would say is eating disorders are just so competitive. I have real mixed feelings of like, how do you put 10, 15, 20 people in close proximity who all have a competitive disease and have that work out well? That’s the part I struggle with a lot, like how do you do that without the vast majority of those people doing worse because of this experience?
Colleen Reichmann: Yes. That’s such an important question for us all to be thinking about. It kind of reminds me – I recently posted something taking a critical eye to especially inpatient treatment centres. I’ve noticed there’s a lot of policing around language that people are allowed to use and certain words are off-limits. Of course, talk of numbers, which is really reasonable, that’s off-limits in groups. Talking about behaviours a lot of times is off-limits. Bringing in things related to politics can be off-limits. Anything too trauma-related can often be off-limits.
So I was trying to say, I wonder how we can have these groups and have them be a really healing experience and maybe let go, loosen our grip a little bit on trying to control language so much and instead try to convey trust that we are trusting people to be able to hold difficult subject matter and use the words that they choose.
A lot of people responded, people who currently work at treatment centres – which I appreciate this discourse – who said this is great in theory, but a lot of times these groups are really struggling with feelings of competition with one another, or there’s maybe people living in different body sizes who it would be hard for one person to call themselves fat if they’re in a smaller body and say it like that’s a negative thing, and for this patient who’s actually in a larger body to hear that – there has to be some kind of controlling of the language.
I think that’s so true. I can really see where they’re coming from, and see where I’m coming from in that post. This is what I’m talking about when I’m saying I’ve been thinking about it a lot more, because I don’t have the answers, but I think a lot of what’s happening on the units isn’t working for some of the people. And like you said, sometimes it’s literally life-saving and incredibly important.
Chris Sandel: Yeah. We’re having a discussion where there is no silver bullet here. I don’t actually have the answer because I really don’t know what the solution is. As you said, in a situation there can be someone who actually has much more benefit by being able to speak more freely and to be able to articulate what they’re feeling and what’s happened to them, and for someone else hearing that story, that is a triggering experience.
I don’t know what the solution is in that. Is it like, okay, it’s fine for them to go through that triggering experience and then they bring it up with their therapist when they then have their individual sessions, and it’s then like, “Cool, let’s use this as a learning experience and we work through this and we’re trying to build resilience”? But where is the line between building resilience and this thing has just put someone back by months because that’s become such a thing for them? Yeah, I don’t know, and I think it’s a really difficult thing to do.
There’s a part of me that feels like if we could get a lot of the benefits that are associated with going to inpatient in terms of having someone be eating more food, having that be prepared for them, taking away a lot of that decision-making that creates the cognitive load of having to make that decision themselves – if you could have that in more of an outpatient type setting, would that be more beneficial? And I don’t know how you’d create that, I don’t know any of those things, but that feels like you’re kind of getting the best of both worlds.
Colleen Reichmann: Right. I’ve thought about, too – and again, this is more imagining a different world or something to all move towards in the mental health field – more community care, and how we could foster that and then create that for people so that – and I think this also comes into play with – I guess this is a whole different area, but suicidality.
When people are struggling with that, I think a lot of times therapists are trained to say, “Time to go to the hospital” or to bring the hospital into that. I think there are some interesting conversations happening around more abolitionist work when it comes to psychology and taking the policed and punishing hospitalisations out of the picture and replacing that with community-based care. Again, right now it’s like imagining what could be and what this world could look like. But I think there are a lot of parallels between those conversations and inpatient eating disorder units.
Although I do want to say, I think they can be so important and so life-saving for some people, and they probably will always need to be in some form.
Chris Sandel: Agreed.
Colleen Reichmann: But I think one thing we can probably agree on is one step they could take that would be helpful, probably across the board, is not saying no if somebody wants more. I also have somebody who told me, “On this specific unit I learned I’m only allowed to have this percentage of an avocado, so that’s all I put on my sandwich now.” I was like, “No! I don’t know why they’re teaching you to limit or be very scrupulous with your avocado.” I sometimes wonder, why are we putting the same mindset onto people that maybe brought them into treatment in the first place? The really black-and-white, rule-based mindset. It seems not productive.
Chris Sandel: Yeah. There’s certain things, like what we talked about before with people speaking more openly, I can see both sides of why it could be helpful, why it could be harmful. I don’t understand the benefit of saying, “You can only have a quarter of an avocado.” I don’t understand what the upside of that is for any human being, let alone someone who is recovering from an eating disorder. That definitely, to me, is nonsensical.
The other one I would say is – and I think this is really common – setting very low weights as a target weight, as like, “Okay, now you are recovered, now let’s do maintenance.” That’s one of the other things I think is very problematic that I see often. And this isn’t just restricted to inpatient; this can happen in outpatient as well. But I know it does happen a lot in inpatient facilities, and I think that number gets stuck in someone’s head; that is seen as “Well, if I’m at this number and I still feel relatively the same as I did before, why would I stick around here? I should just go back to what I was doing before.”
It basically teaches someone, “This is as good as it’s gonna get, and it’s basically the same as it was before, so yeah, just go back to doing what you were doing.”
Colleen Reichmann: Doesn’t it feel like sometimes the height of hubris to think we know? Like, “This weight you will be safe and psychologically different.” Bodies are so intricate and they’re different and individualised, and I don’t know that we should – and I’m not a dietitian, so I shouldn’t really speak too much on this, but the focus on weight in general I think could be loosened a little bit somehow at these places, and the ceilings and floors for weight.
I’ve worked on units where they really insisted that people don’t see their weight, and that worked for some and really didn’t work for others. And I worked on one unit where they insisted everybody look at their weight to desensitize themselves each morning to the number. Again, it worked for some. Honestly, it did. And then there were people who were really horrified by that and asked over and over, “I don’t want to see it, I don’t want to see it.”
To me, it just seems obvious. Let’s pick the battles and let’s have it be individualised. If people want a vegetarian diet, I’ve worked on places where that wasn’t allowed. That doesn’t seem – I don’t know, it seems like there’s a lot of not-individualised treatment that’s happening and that’s hurting people, I think. I could go on for days. [laughs]
00:56:21
Chris Sandel: I think this then touches on, on your site, you say “I’m person-focused and I do person-focused therapy”, and I imagine that is a lot of what you’re talking about here. Like, let’s have a conversation with the person I have in front of me and figure out, what does recovery look like for that individual? What are the best things we can do for that individual where this is a collaborative approach?
Colleen Reichmann: Right. Like, what do you want? I think that’s where harm reduction can come into play, too. There’s benefit in that idea of offering people harm reduction because it’s kind of like, what do you want for your life right now? What do you want to be different, and how can we help you work towards that? How can I help you in this moment?
For so many people, what I want is I want them to have full freedom from an eating disorder, for example, and not be haunted by these thoughts anymore and not use any behaviours. I would love that for so many. But for the people who at least are coming to me, that’s not always what they want for themselves. Should I be pushing my idea of what helps people on everyone, or should I be more listening and meeting people where they are? I’m very much in the camp of, at this point in my career – and just life – I meet people where they are, person-focused and what you want. You get to steer the ship.
Chris Sandel: I agree, definitely, with you on that. And I always want to be very upfront about where I think this could go. Because I think sometimes people are somewhat hemmed in by the amount they can believe recovery could occur. They may feel “The best I could ever hope for is harm reduction”, and if that’s what they want to work towards, we can do that.
But I also want to be an advocate of, there is more on offer here that we can work towards. I think if I don’t say that, I fear that maybe no-one’s going to say that to them, and that idea is never going to have a chance of taking hold. So I want to at least be someone who is telling them that there are other possible options on the horizon.
Colleen Reichmann: Right. This is where I do think the idea of just not being black-and-white – this was really hard for me, I would say, at the beginning of my career. I was still stuck in black-and-white mindset with all of it. Like, either you are for full recovery or you are for giving somebody hopeless messages, like “we’re just going to help you survive” or “this can never get better.”
The longer I’ve been in the field and the more I’ve tried to think about everything and the more I’ve done this work, I’ve realised that’s kind of the beautiful thing about something like harm reduction; it’s really an art. There is an art to saying, if you want to exist with still having this behaviour and keeping the eating disorder in your life, so to speak, I’m here to help you live the most meaningful life and the most aligned life while you do that. And I am going to always be circling back to, do you want something different? Is there room to work towards anything else?
I think it’s an ongoing process and harm reduction doesn’t have to mean forever. I mean, it can for some people, but there is an art to circling back with armfuls of hope for people. Like, “I do have this hope for you. Would you be open to this?” or “Do you want something different for your life right now?” It’s an ever-evolving process.
And truly, I really grappled with that for a while, how to have both – how to believe in full recovery for some people and how to help them towards that, and harm reduction for other people and how to stand with them in that, and a combination of all of it for other people. It’s all grey area.
Chris Sandel: Yeah, it really is. Even when you’re talking about that, I can think of – there are points where someone tries to do harm reduction and everything they try doesn’t actually make any difference. They’re in such a state that there needs to be more of a change for them to get any kind of benefit. Otherwise it is simply moving the chairs on the Titanic. Whereas for someone else who is typically further along with their recovery journey, I can see how harm reduction can work, in a sense, and they can still have a meaningful life, even if that’s being impacted in some way.
But there are times where I’m like, harm reduction for you to actually notice a benefit is going to take more of a change than you are maybe willing to do right now, so it can often feel like it’s not getting very far.
Colleen Reichmann: Yeah, it can. It’s definitely something else that I’ve really worked to do in my career: to always be circling back to, are you getting a benefit from this? Is this therapy helpful for you? I think the reason why harm reduction has been something that at my practice we’ve been talking about more and taking more trainings on and everything is because we tend to see a lot of people with open arms, take a lot of people who have been through the system, so to speak, over and over. People who have been labelled as ‘chronic’, who have tried the levels of care, who feel like this has not worked.
And when we’ve said ‘harm reduction’, there’s been almost a breath of – and I’ve seen people astoundingly be able to change more once that’s on the table. It’s such an interesting and nuanced topic. I feel like we could do an entire podcast on harm reduction. [laughs]
Chris Sandel: In terms of what you said there, if I think of the AA mentality of ‘let’s take one day at a time’ – I think harm reduction may feel more like “Let’s take one day at a time and focus on the thing that I need to do in this moment or in this day” versus full recovery feels like “Now you’re asking me to not drink for the rest of my life, and that feels like this huge endeavour, and that then becomes too overwhelming and I just can’t do this and I can never see how I could ever achieve this.” And that then steps someone in their tracks. Whereas harm reduction, “I could do that.” That feels more manageable.
Colleen Reichmann: Yeah. I’ve seen people, especially people with marginalised identities have really spoken up about different – sometimes full recovery doesn’t feel accessible if you’re living in a body that in our society you’re not safe to live in that body because of these different areas of marginalisation. I think the eating disorder field, when we just pushed full recovery, ignored that for a while. And that’s important to listen to. That’s why I think Black, Indigenous, and people of colour in the eating disorder community have started to say that harm reduction can be helpful for these various populations because sometimes full recovery almost creates a sense of hopelessness. Like, “How could I ever get there when my body feels inherently unsafe because of this messed-up society that we’re living?”
That was one of the things that has really perked my ears up to it. I loved the concept of full recovery, and I still do for whoever wants that – when I first started. But the amount of people who’ve come into my practice who have said it makes them feel hopeless in this moment was eye-opening to me. And it was eye-opening to me like, “Oh, harm reduction creates more hope for me specifically.” I think it more goes back to that point of what we said originally; the individualised, person-centred care is where it’s at.
01:05:16
Chris Sandel: Definitely. One of the areas I know you also talk about is amotivation. This is a term that I haven’t really heard used very often, so can you explain what this is?
Colleen Reichmann: I think it’s a term meant to describe the feeling of not being motivated and not wanting to make any change or not seeing the benefit in trying to create change. I think it’s something that can really haunt people with eating disorders because it’s an egosyntonic illness, at its core. There is an element different than depression, for example. A lot of people who go to a therapist for depression will be saying, “Please help me. This is so awful. Please take this from me. I want this gone.”
And that’s kind of the exception, not the rule, when it comes to people who are struggling with eating disorders. There is oftentimes this, “I’m miserable in some regards or I wouldn’t be here, but I don’t want you to take this from me. This is also very important and I’m not interested in giving it up or motivated to do so.” It’s a unique field to be in as a therapist because there is that egosyntonic element, and I think that’s where the amotivation loops in there.
Chris Sandel: I can imagine “I want you to take certain aspects of this away”, like “I want you to take away the hunger feeling or I want you to take away the cravings that I have or I want you to take away the pain I have in my legs” or whatever it may be. “But in terms of a lot of the other aspects of this, I don’t want to give this up.”
Colleen Reichmann: Yeah, or specific – I find a lot of people are like, “I really want to go rid of binging or purging, but not necessarily restriction.” Or “I do want to get rid of the eating disorder behaviours, but I don’t want to gain weight and I still want to be able to very carefully micromanage my weight.” It’s just different.
A lot of people don’t want to work in the field of eating disorders, and I think that’s because this creates a challenging dynamic, especially between clinician and client or clinician and patient. I think for some people, it can start to create an ‘us and them’ feeling, or like “You don’t want to do this and I’m making you do this”, and that’s challenging, for sure.
Chris Sandel: If this is coming up in a session with a client, how do you deal with it? What is your approach? I know there’s probably going to be lots of different things, but give some examples.
Colleen Reichmann: I think motivational interviewing is incredibly important. And I also think that can really align with harm reduction, by the way, because motivational interviewing is, in my opinion, a really respectful way of approaching these changes that somebody maybe does want to make or is too scared to or needs a little bit of a nudge to start making. I think it’s really helpful for people with substance misuse. I’ve seen it be incredibly important for work with people with eating disorders.
Oh, there’s so many different ways to go about it, but it’s really just conversations with people where you are artfully offering them ways to reflect and ways to think about, why are you here? What’s holding you back from making the change? What are the pros and cons to staying the same? What are the pros and cons to changing? There’s going to be both for each of them. It’s a very, in my opinion, nuanced way of conversing with somebody to try to help them instead of you telling them, “This is what you need to do. This is what I want for you.” It’s a way to help people move towards making decisions that create change on their own.
Chris Sandel: Yeah. Again, coming back to that collaborative approach and taking – I’m blanking on the term.
Colleen Reichmann: Socratic questioning, yes.
Chris Sandel: Yeah, Socratic questioning, like “Let’s look into that more.” You’re getting further and further down to understand how someone’s come to a certain way of thinking or what are their motivations or what’s driving it, and not done in any other way apart from just “I want to understand this better and I want us both to understand this better so we can figure out what’s best here.”
Colleen Reichmann: Yes, I want us both to understand this better and I want to, again, meet you where you are. Whatever changes we arrive at, you should be the director. You’re the person who gets to make the final call. Maybe the change is so, so, so small, and that’s a fantastic place to start. The smallest little change, I’m so on board with that.
01:10:54
Chris Sandel: I know you also have trained in and used dialectical behavioural therapy with clients. I’ve covered CBT on the show before, but I haven’t spoken about DBT. It’d be useful to have a bit of a chat about this. And it’s not something that I have any real experience in, at least in a formal sense. So can you explain what DBT is?
Colleen Reichmann: It’s a type of therapy – it is very similar to CBT in certain ways in that there’s an exploration of the connections between thoughts, feelings, and behaviours. The thing about DBT is that it loops in – the idea of dialectics is foundational in it, which is this idea – whenever I reference the grey area, that’s what I’m referencing: holding two seemingly opposing truths that are both true, holding those at once, and looking for the grey area and nuance. It’s moving away from black-and-white extremist thinking and learning to look for the grey area, appreciate the grey area, hold competing truths at once.
It focuses on these four different pillars. There’s interpersonal effectiveness – essentially your relationships; emotional regulation – that’s kind of self-explanatory; distress tolerance, which is like emotional regulation but more skills to tolerate emotions when they’re at their peak levels; and then mindfulness is also incorporated, which is very different from CBT. Marsha Linehan, who created DBT, was influenced heavily by Eastern philosophy, so incorporates mindfulness practices and coping skills that utilise mindfulness that’s incorporated throughout DBT curriculum.
Chris Sandel: When I think about CBT, a lot of my focus is much more on the ‘B’, the behaviour part of it. I’m quite a believer that people don’t think their way into acting differently; they act their way into thinking differently. It’s not to say that the cognitive side and exploring that side isn’t important, but I do think in a lot of ways when I’m doing this, it’s then in service of some kind of action-taking as part of it. Is that the same with the DBT? You’re talking about the interpersonal effectiveness or the mindfulness or distress tolerance or emotional regulation or any of those things, but it’s then like, how do we put this into practice?
Colleen Reichmann: Yeah, the behavioural aspect is pretty important. DBT was initially developed for people with borderline personality disorder, and Marsha Linehan has that herself. She talked a lot about and incorporates a lot about how to change behaviours that are harmful to ourselves and others and surf urges and things like that. I think there is an emphasis on the idea of ‘nothing changes if nothing changes’, which is so important.
But a little bit different than CBT, in my opinion, there is a lot of cognitive, like, “Let’s focus on pausing in the moment before acting”, and then there’s skills, like, let’s literally look at the pros and cons of this action. Let’s examine this together and not decide one way or another, but just focus on pausing, urge surfing, just taking a moment between stimulus and effect or whatever it’s called, living there for a little bit and examining the cognitive, and then hopefully behaviour change is involved in that after you do that.
Chris Sandel: I would even say that everything you described there is a behaviour change. To say, “I’m going to pause and notice my internal experience here or I’m going to notice the thoughts that come up” – that in a sense can be part of the behaviour change, and there can then be a further behaviour change after that based on what is gleaned from that. But I do think that you’re then teaching someone, “How do I, in a sense, learn mindfulness skills that I can then use in this challenging moment?”
Colleen Reichmann: Yeah, I totally agree. The idea of the moment between stimulus and response and changing how you interact with that moment and what happens there is just beyond powerful. That’s CBT, that’s DBT, that’s people who make changes in any behaviour all around the world. That is such an important piece of it.
Chris Sandel: Is there anything you would add about that little piece in terms of “This is what I’ve noticed can be really helpful with clients” or “I’m regularly talking about this aspect”? Because I agree with you that that little moment can make such a difference, but I just wonder if it’s useful for us to linger here and comment any more about it.
Colleen Reichmann: I think there’s so many different things that work for so many different people, but the idea of lingering in that moment and then checking in with your body is really helpful. Like, what’s my body telling me right now? What do I notice about physiological sensations? What’s my pull? What is the thought? What’s the urge right now? And then – this is why I do think the cognitive side comes in – instead of acting, considering. And I guess mindfulness comes in here, too – what that thought is and where it’s coming from and the messenger, I guess. And the emotion, too, that you’re experiencing. What’s the messenger of the emotion?
All of this takes an incredible amount of practice, in my experience. But it’s kind of what I was referring to at the beginning when I said when I have random thoughts and urges now, instead of just acting on them, like I would in the past, I’ve really cultivated a practice of pausing and considering. Like, “Oh my gosh, where is this coming from? That’s so fascinating that my brain still does that. I think this is my brain being like, ‘You are so upset and so in distress right now, and I just want to help you. This has worked in the past. You want to try it again?’” And appreciating that for what it is and then not acting on it. Choosing to act in a different way that’s more long-term helpful – that’s life-changing.
Chris Sandel: Totally. I think the bit that is at the heart of what you’re describing there is curiosity. Like, isn’t this curious? Isn’t this interesting that that thought has popped into my head? What does that tell me about this situation?
And sometimes it’s like, it tells me nothing about this situation. It is just a completely random thought and I need to move on with my day. And other times, it’s like, that is really interesting. Maybe I didn’t get enough sleep or I do need to pause and go and grab a snack, or yeah, I have been thinking about that thing my mum said and I really need to get back to her. It can be quite enlightening. But it’s only enlightening when you take it the next layer down. It’s not the surface-level response, but more like, okay, what is this now pointing to?
Colleen Reichmann: Yeah, and it can be so, like you said, multi-faceted, and it doesn’t have to mean anything about that moment. Like, “Oh wait, I’ve noticed this in the past seven months after having my daughter. You know what this means, I think? I’m very sleep-deprived. Things have historically – I’m not a person who functions super well with sleep deprivation, and I think things would feel very different if I had more sleep right now, or if I had a glass of water and was able to breathe and sleep.” It doesn’t have to mean anything super deep, for lack of a better term, about the actual thought or emotion. It can mean exactly what you’re saying – different coping skills, and little changes would be helpful right now.
Chris Sandel: Yeah. It’s also really obvious when having ids. I notice it with my son. There’s times where I’m like, there was this impulsive behaviour or something that came out of nowhere, and some of it I’m like, I can understand that this thing has happened or that thing’s happened, I can really trace it back. And then other times I’m like, he just got hit with an emotion, and that in a lot of ways came out of nowhere. And maybe it is connected that he didn’t have enough sleep the night before or whatever. But I also think of myself; there are days I wake up and I’m like, “Meh, just don’t feel as good.” Or there can be afternoons where that happens. Or there can be days where I feel really great even when everything’s really shitty around me.
I think sometimes as humans we’re just hit with things that really don’t make sense, and it’s about having the discernment to be able to figure out, is there some very obvious cause and effect connected here that I need to look into? And other times it’s like, I just need to move on.
Colleen Reichmann: Yeah, I totally agree. I think with what you said with your child – have you heard of gentle parenting?
Chris Sandel: I don’t know. I’ve got so many parenting books.
Colleen Reichmann: Me too. [laughs]
Chris Sandel: It’s undoubtedly come up, but I don’t know specifically what gentle parenting refers to.
Colleen Reichmann: It’s similar to responsive parenting. A lot of the conversations around – I really love a lot of what people who advocate for that parenting style say, but one thing that I find dangerous is this idea that every reaction from your child is because of an unmet need. I find parents getting very much caught up in like, “They’re crying so I’m not meeting some deep emotional need.”
To me – and this is why I love DBT, by the way – we are all so prone to black-and-white thinking and taking something and being like, “This is it. It’s either this or this.” Really, things can so often be an unmet need for our kids – and just like us, sometimes they’re just experiencing more of a random wave of emotion or woke up on the wrong side of the bed, and it doesn’t need to involve incredible digging and exploration. The ‘and/both’ is so important for eating disorders, for parenting, for basically everything in life.
Chris Sandel: Totally agree. And I think there’s so much of an overlap there between what happens with an eating disorder. So often in recovery, clients will say, “I can’t believe I’m still having this thought or that this thing came up for me.” Again, sometimes it’s worth really exploring it, and other times we do a little bit of exploring and it’s like, it just happened. There is no deeper meaning to this. Thoughts think themselves. You are a witness to those thoughts, and that’s the end of it.
Colleen Reichmann: Yeah. I will often talk with people about the thoughts, and it’s not that they don’t matter, but you can have really scary thoughts or thoughts that are very disturbing – and this happens with people with OCD a lot. They don’t necessarily mean much. They don’t have to mean something deeper. The behaviour and the action that really matter, stemming from them. Again, that sounds super reductive and that’s probably oversimplifying it, but there is something to not attaching huge significant meaning to every single thought. That’s a recipe for a lot of discontent and a lot of anxiety.
01:23:47
Chris Sandel: Agreed. Let’s talk about your book, The Inside Scoop on Eating Disorder Recovery that you co-authored with Jennifer Rollin. How did that book come to be?
Colleen Reichmann: That book was brewing in my mind for years and years. It’s a good example in my life of resilience. I have so many rejection letters from book agents and publishing companies. I must have 30+ letters saying, “Not for us right now.” And that was when I was trying to do it on my own.
Jen and I have been friends for some time, and I mentioned to her – throughout the process, I had mentioned to her, “It’s not working. Nobody seems to care.” One person even said to me something like, “Why would somebody pick up your book when the book next to it says ‘the diet that will change your life, an easy 1-step solution to happiness’? Why would somebody pick up your book when they could pick up the one that says ‘just change what you’re eating and restrict this and you will find happiness’?”
I was sharing that with her and feeling really defeated by it all, and she floated the idea of, “What about co-authoring it? And what about these changes? What about if we took it in this direction?” I love writing, and I don’t love – what would the word be? Networking and things that Jen is fantastic at. So it was kind of like once we joined forces, the pair of us – that’s how it all happened. She was a real game-changer in having people listen to us and taking notice of the book. We were an unstoppable team together.
I had the foundation of the book laid out, and then she had some great ideas to add in, and we wrote it together – and did so in a way – I’m really proud of us because there were never any arguments. It was always a fun process, and we stayed very good friends throughout the whole writing process and publishing process. And I’ve heard that that is a little bit rare. So I’m always continuously proud of us for doing it.
Chris Sandel: Nice. That is good. I think I’m probably more like you than like Jen. I like writing, and networking not so much.
Colleen Reichmann: Yeah, she’s so much better at all that than I am. [laughs] I really prefer to sit behind my computer and just write alone in a room, and then be like, “Hope someone reads it! Let’s see what happens!” [laughs]
Chris Sandel: I think it’d be useful to spend the remaining time that we have going through certain parts from the book.
01:26:54
One of the ideas you talk about is ‘acting as if’. Do you want to explain what this is?
Colleen Reichmann: Sure. It’s kind of related to what you were mentioning before with behaviour change and then thoughts and emotions can change. It’s the idea that you take action even if it doesn’t feel fully aligned, and even if a lot of things in you are screaming that this is wrong. It’s taking the action that you know, long term, is what you’ve decided will help, is what you want for yourself, and will lead you towards the path of maybe longer lasting peace.
It’s put in a very simple way, but it is hard. A lot of times it’s the basis for behavioural modification for depression. Making yourself do something when you’re feeling very depressed has been research-proven to, in and of itself, help with depression. The most simple example is getting out of bed. A lot of times when you’re deeply depressed, that does not feel like something you want to do. It’s actually really, really hard to do. And doing that or forcing yourself to see someone and have some sort of social connection – after the fact, longer term, that is much more helpful to you, most likely, than sitting in bed.
We applied it to eating disorder recovery in the book. A lot of it does come down to you can talk and talk – if you’ve been restricting heavily, for example, it’s easy to talk about – not easy, but we can get into the pattern of talking about eating the fear food or talking about making these changes, and then the actual next step is really hard and feels not good. But it’s the push to take that step anyway and eat the food and not use a behaviour, do the thing, act as if that’s the aligned action. Because it likely is. And then just continue to do it. It’s like a pattern-breaking cycle.
Chris Sandel: The reason I like this and wanted to talk about it is because in the beginning, so much of recovery feels like a leap of faith. “I do this action, I feel more uncomfortable, I feel like I’m worse off from doing this. I don’t see any positive benefit from doing it, and then I have to do it again and I have to do it again and I have to do it again.” There is some point that you reach where there is a benefit that you start to notice from doing those things, so you do then have this feedback loop that shows, “Oh, when I do this, now I feel better” or whatever.
But in the beginning there isn’t that positive feedback loop. It feels like “I’m going in the wrong direction” or “I’m doing things that feel more anxiety-provoking, and I get no upside for it.” So I think with all of this, there is marginal gains, and when those marginal gains are added together, at some point you start to notice a benefit. But not in the beginning. I think it’s useful to know that in terms of managing expectations, because I think that can be the trap of like “But I thought I was going to feel better in recovery.” It’s like, you are – just not now.
Colleen Reichmann: Yeah. There’s a quote that I think I put in the book about recovery feeling like frostbite – that it hurts more. As you thaw from frostbite, first you’re frozen and then you’re thawing, and it hurts obviously a lot more than when you were frozen, and you have to go through that where it hurts even more sometimes before you start to feel the relief.
The CBT, the older way I would and still do explain it to people – my best example of this is I had a very obsessional relationship with waking up very, very early and going to the gym quite religiously at one point. To break that, I had to ignore the time. When that time came in the morning, I had to over and over surf that wave and just sit there. It was – I can’t use any other word but excruciating, at first, to feel all of that.
But what was happening was I would start to get the anxiety of not going when I was very much in the eating disorder, and it would rise and rise, this cresting wave of distress and anxiety, and then I would interrupt it like, “Okay, I’m going to get up and go, and that will bring it down.” So I never had the experience of having it rise and crest and eventually fall without me doing that interrupting.
It often takes doing that, watching it rise and fall on its own or without using your behaviour, many times before it starts to feel better. But it will eventually feel better, if you just act as if and stay the course.
Chris Sandel: Definitely. That ties into something else you talked about, which is an analogy I love: your eating disorder voice is similar to that of a dictator. Obviously, when you’re starting to do things that go against what the dictator wants, they get louder and angrier, so things appear worse to begin with because that’s, in a sense, what’s going to happen with a dictator.
Colleen Reichmann: Yeah. When you start disobeying or making changes, typically bullies or dictators won’t just slink away like, “Okay. This person is changing.” They’re going to get mad at first, even louder. It does feel like that. It feels like it hurts even more. That’s why I truly can appreciate why so many people want to turn back and do turn back at this beginning stage. And we try to make it clear in the book that there is research to show, and personal experience, lived experience shows, that if you stay the course and you continue doing these actions, that distress won’t always be there. That will change.
Chris Sandel: Definitely. I had a recent guest on, Sasha Gorrell, and we talked about eating disorders, specifically anorexia, as being an anxiety disorder. With anxiety disorders, the way that they’re dealt with is through exposure therapy and continuing to expose yourself to – whether that be a challenging food or a challenging experience or whatever it may be, so that you desensitise yourself and you learn to be okay with that experience. I think the same way with the eating disorder voice. With time, it does start to change.
Colleen Reichmann: I totally agree, and I think that exposure element is pretty imperative. If someone does want things to change, like you were saying before, that’s very necessary to have that repeated exposure.
01:34:36
Chris Sandel: You have a whole section in the book all about emotions. I can ask you specific questions, but is there anything you would want to talk about straight off the bat?
Colleen Reichmann: I think that’s probably one of my favourite sections in the book because we talk about emotions being messengers, and they are there for a reason – which I was really well-versed in my younger days in numbing emotions and running away from them and using all sorts of fantastic techniques to get away from them. I think it’s so common and so unhelpful to us, at the end of the day, because we evolved with them for very specific reasons.
Even if their phobia, for example, is an emotional reaction that’s gone awry, that’s important. The idea is not to be like, what’s this very irrational fear telling me? Because the messenger there has gone awry. But it’s important to know it started for a reason. Evolutionarily speaking, we had fear for this reason, and then there was this misfire one day. That’s simplifying it, but listening to or understanding the reasoning for them is helpful across the board with so many mental health issues. So that’s what we try to do in that chapter, lay that all out.
Chris Sandel: There are two journalling prompts that I found really useful as part of this. One of them was looking at, how do emotions help you? So how does sadness help me, or how does anger help me, and so on. And then adding in an extra bit of like, “My eating disorder has impacted on my ability to feel sadness by…” or “My eating disorder has impacted on my ability to feel anger by…” I just thought that was a really nice way of starting to explore emotions.
Colleen Reichmann: Thank you. I swear that should be taught in schools. Along with algebra and all the stuff that we might not even need at the end of the day, there should definitely be classes on “This is what this emotion tries to show you” or “This is the evolutionary basis for this emotion.” How do you experience it in your body? How do you know when you’re feeling it? What’s it trying to share with you? How do you know when it’s maybe misfiring? I think that should all be taught in schools.
Chris Sandel: I am completely in agreement with you. I think school should be much more about how we create human beings who can be in this world and be forces for good in this world as opposed to just “here is how you learn to speak French” or whatever it may be.
Colleen Reichmann: Yes, I agree.
Chris Sandel: The other journalling prompt I really liked in this section was “If I wasn’t constantly thinking about my food and my weight, I would likely be thinking about (blank), which would leave me feeling (blank).” Starting to explore, what is this doing for me? What is this helping me to avoid, or what is the upside that I get from staying in this position?
Colleen Reichmann: Yeah. That one came from that one therapist that I mentioned back in the day. I remember she asked me that. Like, “Maybe just hypothesize, if you weren’t thinking about all this all the time, what might you be thinking about?” I was like, “Uh, a lot of stuff that I don’t want to think about. A lot of stuff that leaves me feeling like X, Y, and Z.” That was a pivotal question for me, I would say, in therapy. So I definitely wanted to incorporate that.
Chris Sandel: Nice. For you personally, how did you then use that? Was it a pivotal moment where you were like, “Okay, I am actually starting to explore some of those things, I’m going to do some journalling about this”? What did that look like in terms of it being helpful?
Colleen Reichmann: That’s an important thing that I should emphasise. It was not pivotal in the moment. It was of course a “Wow, there are a lot of things” – and then it wasn’t an immediate “And I’m going to start to explore this, or I’m going to bravely venture into it in therapy.” It was like, “Yep, definitely don’t feel like looking into that. This eating disorder works really very well. I don’t like thinking about this stuff.”
It took years after that for me to begin – but it was a seed planted in my mind, and I think that’s a lot of what therapists do and what they can be helpful with, is planting seeds. Maybe the next therapist then gets to help the person grow. I always say – have you heard about how bamboo grows?
Chris Sandel: No. [laughs] What a random question. When I started the podcast, I did not think I was going to be asked this question today. But go for it.
Colleen Reichmann: [laughs] Bamboo apparently – you can fact-check this, but what I’ve heard is that you plant the seeds for a bamboo, and a year goes by, nothing happens. Another year goes by, nothing happens. Four years go by, nothing happens. Then on something like the fifth year, it will shoot up out of the soil or the ground and grow several feet very quickly.
So with therapy and with eating disorder work, for myself and then for a lot of the people I work with, I think of those years where it feels like maybe nothing’s happened or you’re falling down and getting back up and falling down instantly again. It’s kind of like bamboo. Things are happening; you just can’t see the breakthrough yet. Your bamboo hasn’t shot through the soil yet, but things are still happening. You are not wasting your time.
Chris Sandel: I really love that as an analogy. Even if it turns out not to be true. The whole if you put a frog in water and then slowly turn it on and boil it, it will not jump out – that’s actually not true, but I think it’s a really useful thing that you can talk to people about. So yeah, even if this bamboo thing turns out to not be true, I like that as an analogy.
Colleen Reichmann: I should fact-check it, because I’ve used it so much that I had an intern knit me a little bamboo plant at the end of the year, because I was like “Oh, bamboo!” So I should really fact-check myself. But yeah, regardless, the sentiment remains, and that was very much my experience. I think I see it for so many that I work with as well.
01:41:32
Chris Sandel: One of the things – and I can’t remember how much you talked about this in the book or maybe I just got a sense from looking on your Instagram page – is laughter or being funny is an important part of the recovery process or how you think about helping people. Talk a little about this.
Colleen Reichmann: I noticed for myself – that was something very, very, very important to me that my eating disorder completely took away. This isn’t the case for everyone, but I do think for a lot of people. My sense of humour was gone. I just couldn’t – there was no humour in my life. I dint find humour in anything. I could not laugh. Once I started to get more of a taste of recovery, especially in graduate school – I remember crystallised moments in my mind where I was like, “Oh my gosh, I used to do this. I used to make these really weird, funny videos with my friends, and I used to laugh really, really hard, to the point where my cheeks hurt. I forget what it feels like.”
So now I do think it’s important. That’s always something that I want to keep in my life, and it’s another research-proven thing. Laughter is so helpful for a lot of us mental health-wise. We begin to laugh in infancy for a reason. It is very much an interpersonal effective tool. It’s important. So I think when it comes to recovery, when it comes to being a therapist, when it comes to being a human outside of my therapist identity, I find laughter to be one of the most important parts of life.
Chris Sandel: I agree. I will often use it as a yardstick with clients, where you can see that they are laughing more easily, they are smiling more easily. It’s obvious that improvements are happening. Or “My partner was just saying that I’m laughing a lot more, or I’m telling more jokes the way that I used to” or something along those lines. I do think that that can be a really useful indicator.
And even just with the way that I am with clients. Where it’s appropriate, I will be funny or try and bring in laughter or whatever because I think this can be very heavy work, and I think laughter is kind of useful in terms of, yes, this is serious, but I also want to see the non-serious side of this. There is something really valuable in doing that.
Colleen Reichmann: Yeah, and looking for the lightness. You know what I think is a peak functioning human, in my opinion? When you are able to use humour and laughter and have it not be mean. I think about this often, and I think that’s where therapy is like an art. So much of humour can be a little bit cruel, or that’s a lot of it for certain people. So if you can use humour, especially in the therapeutic sense, or just with yourself or other people, and it’s not mean and it’s truly funny, that is peak human experience, in my opinion.
Chris Sandel: I would agree. Are you a big movie fan? This was the impression I got from looking at your Instagram and looking at the funny, jokey videos that you would make, that you must be quite into movies.
Colleen Reichmann: I am into movies. That’s one of the sadnesses of parenthood, that I haven’t been able to watch movies as much. But I’ve always loved movies. My brother is a huge movie fan, a huge horror movie fan. He’s also very into comedy. So yes, I love movies.
Chris Sandel: Colleen, this has been a really wonderful conversation. I’m so glad we got to do this. Where should people be going if they want to find out more about you?
Colleen Reichmann: If they’re looking to find out about therapy, you can go to my website, which is www.colleenreichmann.com. And then just for my musings or little tid-bits of recovery advice or humorous things, you can look on Instagram, which is @drcolleenreichmann. I have a Substack if you’re interested in essays about motherhood, which humour enters that a great deal as well, which is Musings From a Mama. I think that’s it. I have a Facebook, but I’m not really active on it. And then my email is colleenreichmann@gmail.com.
Chris Sandel: Perfect. I will put all of those things in the show notes. Is there anything we didn’t cover that you wanted to mention?
Colleen Reichmann: I don’t think so. I’m really appreciative of the conversation, so thanks for having me.
Chris Sandel: It was my pleasure.
So that was my conversation with Dr Colleen Reichmann. She’s doing incredible work helping those with eating disorders and body image issues, so I hope you enjoyed this conversation.
01:46:49
There are two recommendations that I want to make, and they are somewhat interlinked. The first is a book called Bittersweet by Susan Cain. Susan Cain is also the author of Quiet, which is a book about introversion that I read a number of years ago and loved. The subtitle for Bittersweet is How Sorrow and Longing Make Us Whole. I’m going to quote the blurb for the book:
“Bittersweetness is a tendency toward states of longing, poignancy, and sorrow; an acute awareness of passing time; and a curiously piercing joy at the beauty of the world. It recognizes that light and dark, birth and death – bitter and sweet – are forever paired.”
Bittersweet is a book about the emotion of bittersweetness and how, really, in a world that tries to push endless positivity, there is value in being bittersweet. There’s actually a large overlap between high sensitivity and this emotion of bittersweetness, so it feels relevant for many clients, as so many of them identify as highly sensitive. I identify as highly sensitive myself, and I found it a really helpful book in the same way I found Quiet a helpful book, where it gave a vocabulary and an understanding to introversion and the power of introversion and how helpful that can be. I think the book does the same here for this feeling of bittersweetness that can sometimes feel maligned, but actually has some real power.
It’s beautifully written. I think Susan Cain is a fantastic storyteller. She’s also the narrator of the audiobook, so very enjoyable to listen to. I highly recommend checking it out. It’s called Bittersweet by Susan Cain.
The next recommendation is a documentary, and it’s called Roadrunner. It’s all about the life and death of the chef Anthony Bourdain. I remember reading Kitchen Confidential, Bourdain’s book, in 2003 or 2004. It was shortly after arriving in the UK, and I just really loved it. It was this book that really catapulted Bourdain on a new trajectory of life. He was at that time in his forties when it came out, and he was a chef who was barely making ends meet and was living paycheque to paycheque, and this book then led to him being on TV and having multiple travel shows that ostensibly were about food, but over time became less and less about food and more and more about people or the places. It was him then for the next couple of decades, nearly, travelling the world.
The reason I said that these two recommendations are interlinked is because as I watched the documentary, it was like I was witnessing bittersweetness incarnate. I would hear Bourdain have conversations, and it was like he was using statements pulled straight out of Cain’s book. For Anthony Bourdain, this went much further than bittersweetness. He was a recovery heroin addict, but someone who simply channelled what was heroin addiction into other addictions and other behaviours. Sadly, he ended up taking his own life, and the documentary shows the demise that led to this place.
I thought it was a really well put together documentary, the interviewing of those who knew him and loved him and worked with him well and just how much he is missed. So I highly recommend checking it out. It is called Roadrunner, and as I said, I think it pairs very well with Cain’s book in terms of seeing someone who is of this bittersweet personality type.
That is it for this week’s episode. As I mentioned at the top, I’m currently taking on new clients. If you want help with an eating disorder or disordered eating, chronic dieting, poor body image or exercise compulsion, getting your period back, or really any of the topics that I cover as part of this show, then please reach out. You can head over to www.seven-health.com/help for more information.
I will be back next week with another episode. Take care, and I will catch you then.
Thanks so much for joining this week. Have some feedback you’d like to share? Leave a note in the comment section below!
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