Episode 7: How Do You Treat an Eating Disorder?: A stimulating conversation with Dr. Melanie Smith, Director of Training at the Renfrew Center
[Bouncy theme music plays.]
Sam: Hey, I’m Sam!
Ashley: Hi, I’m Ashley and you’re listening to All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders. We want to create a space for all bodies to come together authentically and purposefully to discuss various areas that impact us on a cultural and relational level.
Sam: We believe that all bodies and all foods are welcome, we would love for you to join us on this journey. Let’s learn together.
Ashley: Hey everybody, thank you so much for joining us today. We have another wonderful guest speaker with us today. Dr Melanie Smith, PhD, LMHC, CEDS-S is the director of training for the Renfrew Center. As the director of the Clinical Training Department she is responsible for developing and implementing clinical training and programming that is consistent with emerging research and evidence based practice. Dr. Smith is co-author of the peer reviewed treatment manual and patient workbook The Renfrew Unified Treatment Model for Eating Disorders and Co-Morbidity, published by Oxford University Press. Dr. Smith is a certified eating disorder specialist and approved supervisor, a certified therapist and trainer of the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders, U.P., and holds a certification in Trauma Informed Care, T.I.C. Thank you so much for being with us today, Mel. We are so looking forward to our conversation and, yeah, thanks for being here.
Melanie: Thank you for having me. I’m honored to be part of this.
Sam: Melanie, thanks for being here. I have a question about your role at Renfrew, would you able just to talk a little bit about your role at Renfrew and CED-S, what that means. I know there’s a lot of people in the audience, they’re probably thinking, “I wonder what all the,” I mean, you have like a whole alphabet after your name. Yes, yes. So, would you be able to talk a little bit about that?
Melanie: Sure. Yeah. Well, my role at Renfrew, my title is Director of Training, which is specific to clinical training. So, really providing educational and clinical support to all of our clinicians across disciplines. So, you know, primarily a lot of work with the therapist obviously, but also cross training, because we believe in a certain set of psychological principles that we’re going to talk about a little bit later. And it’s really important that all of our staff of all disciplines have training, and supervision, and support around that. So, working closely with dieticians, with psychiatry, nursing staff, in order to make sure that all of our clinicians at all of our locations, which is not an easy thing to do when you have different locations and different folks at all the different places, to kind of make sure we’re rolling in the same direction, that we’re providing treatment in a way that’s consistent with evidence-based practice, that’s consistent with our core values as an organization and treatment program. And making sure we’re ultimately on the same page which, again, is not actually that easy to do when we’re kind of spread out across the country? Um, yeah.
Sam: What is it, like 19 sites at this point?
Melanie: Yeah, 19. And I can’t remember how many states that fleshes out too, but, you know, east coast to west coast. So, trying to keep everyone kind of speaking the same language, right? Which is really important too when you think about the fact that our patients are from all over the place and may be in a treatment program in one location, right? Like Philadelphia or Florida, and then step down to another location, like Chicago or Los Angeles. And in order for that to be smooth and to be hopefully most effective, right, we need to all be kind of doing the same thing, speaking the same language, working towards the same goals and the same interventions. So that’s my department’s role, is to try to make sure that we’re all kind of doing that.
Sam: Exactly. I think, you know, one of the questions I get so frequently from, whether it’s a prospective patient or a family, the same question comes up over and over again. And it’s a pretty simple question. It’s like, “How do you treat eating disorders?” You know, and especially because most people are surprised to learn that it’s so rarely just an eating disorder. It’s usually an eating disorder and trauma and depression and anxiety. And it’s sort of a mystery, I think, to people, you know, they’re like, “How do you treat an eating disorder, you know, do you just put food in front of them?” And so, you know, Renfrew has this treatment model, would you be able to just shed some light on how does the magic happen?
Melanie: How does the magic happen? What’s the secret sauce? Well, I mean, the first part of your question is such an important point for people to realize, is that not only does it, um, is it unusual to see someone with an eating disorder that doesn’t have any other mental health problems, it’s almost, I would say almost never. And I mean, for a variety of reasons, but one, you know, if you think about someone who’s experiencing, you know, a moderate to severe eating disorder, that is very disruptive in someone’s life. Disruptive to relationships, disruptive to academic pursuits, work related pursuits, you know, anything that’s kind of important in someone’s life is disrupted. And it would be hard not to then also be experiencing co-occurring depressive symptoms, anxiety symptoms. And I mean, I thought this was true before, but I definitely think it’s true since 2020. That, you know, you’d be hard pressed to find people, whether it be people that are sitting in the client/patient chair or someone that’s sitting in the clinician or therapist chair, that hasn’t experienced some form of traumatic experiences, whether it be communal, you know, communal trauma that we’ve all kind of experienced throughout the pandemic and what we could call a pandemic of kind of racial injustice and reckoning, to just all of those other, you know, individual events and incidences that can happen that can result in a pretty significant ongoing trauma response. So, um, so yeah, almost never would you see an eating disorder presenting by itself, which does create all sorts of interesting challenges that result in people saying, “But how do you do it?” Right? How do you how do you treat disorder?
Sam: Yeah, right.
Melanie: Which is how we landed on really wanting and needing to take a more transdiagnostic approach to understanding eating disorder symptoms and like, what are the kind of core underlying mechanisms that kind of get eating disorders started and keep eating disorders going. Because if we do that, right, if we’re taking a transdiagnostic approach, looking for core underlying mechanisms, we have a much better capacity to heal the problem at the root, right? Because if we’re looking at what’s driving the disorder and the symptoms, because the eating disorder, kind of those external symptoms on the outside, right? Binge eating, purging, restriction, other compensatory behaviors. But those are a symptom of an emotional problem. So, it’s actually much more efficient and effective when you can target those things versus just looking at the, kind of those external symptoms which can switch and change and evolve over time. So, this recognition of this like problem of comorbidity is really what directed us to the approach that we take now, which is a transdiagnostic approach.
Sam: Which is really about targeting the common denominator.
Sam: Targeting the emotional avoidance so that you’re treating everything at the root across the board.
Melanie: Right. So if we treat that and we treat that effectively, right, at the root level, and if you can imagine like a root, like branching out into a tree with branches and leaves and each one of those branches might be a different kind of symptom or presenting problem that someone might come into a therapy office for, if we can treat, again, the problem at the root, we’re gonna be much more effective at really making progress and improvement along all the branches and the leaves that come there. And you said it, Sam, it’s you know, emotional and experiential avoidance is that kind of core problem. And what we mean by emotional and experiential avoidance is just kind of that sense that all of us have. I am, you know, an A-plus emotional avoider. Most of us are. We’re kind of taught to be that way, we’re conditioned to be that way. Because most of us don’t want to feel uncomfortable, we don’t want to feel distressed, we don’t want to feel out of sorts, and when we start to feel that way and our brain and body start talk to one another and it’s like “I don’t feel good, I don’t like the way this feels,” our instinctual natural inclination is to run for the hills, right? To avoid it at all costs. So, some of us might actually run and, like physically—
Sam: Like, literally run.
Melanie: Literally run, right?
Sam: Leave the room, leave the party.
Melanie: Leave the situation, push the food, you know, away off the plate and be like, “Nope, this doesn’t fit within my comfort zone rules.” Which again, is very conditioned and supported, kind of by the systems in society that we live in, because again, we all kind of equally seek pleasure and avoid pain. But the problem is that that avoidance of that pain doesn’t allow us to learn from it, to work through it to grow from it. And that that’s really what we’re trying to do by, was actually go for the thing that you’re running away from, which on the first glance might not be very amenable or exciting to most folks like, “Wait, no, no, no. I’ve done a good job of running away from this, I’d like to continue.”
Melanie: And the running away way works, kind of, in the short term. None of us would do it if it didn’t kind of work to give us at least a little bit of relief in the moment from our discomfort. But in reality, especially when talking about eating disorder symptoms, or you could switch this out with substance use disorders or self-harm or, you know, any other kind of behavioral symptoms stuff that happens, is that, you know, it catches up to you, often quicker than you would like. And the long-term outcome is so much more problematic than actually allowing yourself to deal with your emotional stuff as it happens. But we’re not taught to think that way. We’re taught to, you know, in that moment, to get away from the threat. Um, to avoid.
Sam: Right. I’ve noticed even on social media, it seems like there’s a whole community, you know, so many memes and jokes about being emotionally avoidant. You know, to the point where it’s such a part of our culture, kind of like “I came, I saw, I left.” You know?
Sam: You know, that it’s become so normalized and it’s so relatable, and at the same time, your world gets very small.
Melanie: Yeah. Yeah. Exactly.
Sam: You know, relies on that avoidance.
Melanie: Right, right. Because I mean, again, if you’re just thinking about the most visible or obvious eating disorder related symptoms, right, around, like, rules around food, about what I eat, how much I eat, when I eat, under what circumstances. You know, the more of those rules that you have, the more you end up having, right? Like that, that rule list gets longer and longer and longer of all the things you’re not willing to do because they make you uncomfortable, right? And when we lower our uncomfortable threshold, because we don’t practice being uncomfortable, it just keeps lowering and our life just gets smaller. So, the longer the list of rules of things I’m unwilling to do or feel or experience, the smaller and smaller and more limited that my life becomes. So, we really, you know, focus very early on in treatment is one, just kind of shifting that understanding that like, “Wait a second, running away from the emotion isn’t actually the solution.” That’s the solution you’ve tried thus far, but it obviously hasn’t worked super well because you wouldn’t be in treatment for your eating disorder if it was like foolproof and perfect. And that really it’s a paradigm shift in the way that we think about this as a problem versus a solution
Ashley: Melanie, so speaking of treatment, you’ve been in many different roles at Renfrew, including a therapist at the residential site in Coconut Creek, Florida. Can you tell us a little bit more about what residential treatment looks like?
Melanie: Sure, yeah, I mean, I started working actually in the Aftercare and like Discharge Planning Department back in 2008. So, I’m on year 14.
Ashley: Okay, yay!
Melanie: Yeah, so I have I have a little bit of experience. Um, but yeah, I mean, Residential treatment is all encompassing, right? Because it’s, you know, you’re living in the environment. And one of the things that I think is really good and important but also really hard about the experience of being in residential treatment, is that it is 24/7. And so the good part about that, right, is that we can provide treatment in a much more, like, potent concentrated dose, because treatment doesn’t start and end at a distinct time. Because treatment and improvements and growth from treatment can happen early in the morning, late at night, over the weekend. Because we—and like most residential treatments, would employ like a therapeutic milieu model, meaning that healing can happen in and all of that space in between, not, again, just during the 50 minutes of the therapy hour, or the 50 minutes in a group therapy session. So, it’s incredibly powerful experience, but again, powerful experiences are hard, right?
Melanie: Because you give up some of that autonomy, right? You don’t decide, as the way that you would when you’re at home necessarily, what time you wake up and what time you go to sleep. There is some choice in that, of course, but like there’s a schedule and a routine which can be hard to adjust to, but so important when you’re trying to do big change work within yourself, you know? So, it seems like and feels like, certainly for the folks that get the most out of treatment and really have some of these more transformative experiences, which is such a beautiful and inspiring thing to see as a clinician. Because you’re not guaranteed that with every human being because we’re all human beings and we all have different stuff going on, and we all respond to things differently, and I might respond to things differently now than I would six months from now or six months ago. So, you know, the experiences are so unique, but as a clinician, what fills me up are when we see these transformative experiences, and those experiences come from kind of surrendering some of the intense rigid control that we try to keep, which often, again, is keeping us in that small, limited life box of like fitting in my rules of comfort. And when we start to let that go and allow ourselves to get outside of our comfort zone, do things in a way that is just notably different than I would do them on my own, that’s when change happens, that’s when it happens. At the meal time, in the group therapy session, in the hallway, you know, and uh yeah. I’m not sure if that answered it exactly.
Ashley: No, it does!
Melanie: I’m a believer in the power of the experience overall. And it’s the totality of the experience, it’s no one specific service, or one specific treatment intervention, I think it’s the way it all kind of cumulatively comes together, where we see that like bigger, bigger transformations and changes, which is great.
Ashley: Well, and I can’t help but think, you know, as we were talking about the huge avoidance patterns that we might see with eating disorders, how residential treatment can really kind of, hopefully, interrupt some of those, especially if the desire or the behavior was literally physically running away, right? Like, they’re there and that is a big transformative moment for them to actually be there and be in it. So, thanks, thanks for sharing that.
Melanie: Yeah! Well, and be supported when you’re doing it, right? Because you’re trying to create this big change within yourself, but “I’ve just got to rely on me,” you know? Like, that’s a narrative that’s kind of very popular in our Western cultures, that like you gotta figure it out yourself and if you are strong and you are determined you can do it. And I worry about that sort of thinking, because then it can certainly lead any of us to feel really disappointed in ourselves and really, you know, frustrated with lack of progress. But that it’s not about just doing it on your own, it’s about doing it alongside other people who are also doing it, which again is so powerful about kind of that group living experience and group therapy experience. And to be supported by people who have seen the beginning, middle and end of this for lots of other people, who know and believe, like myself, that like you can and will come out on the other side and you will be stronger for it.
Melanie: Not without some tears and some snot—
Melanie: But in a way that, again, is growth fostering and builds you up. Not in any way of tearing down, this is not a treatment in which we’re trying to strip you away of your identity and trying to, you know, I don’t know. That there’s definitely, um, again beliefs out there, that that’s what residential treatment is about and it’s not. It’s about uplifting people to do the hard work. But it is hard work!
Ashley: It is definitely hard work.
Sam: So, you know, we talk about targeting emotional avoidance. How exactly, I’m sure there’s people out there wondering, how exactly is it targeted in treatment? You know, like literally, like, I get these questions all the time that’s like, “But how do I feel my emotions? How do I not avoid?” Like what are some examples that you’ve seen in residential treatment, when you talk about in the hallway, when you talk about at meal time? What does that look like?
Melanie: Yeah, well and those are actually again the times where I probably feel like it illustrates it the best, right? Because if you’ve got, you know, a caring, compassionate and knowledgeable professional walking alongside you, they’re going to get to know you pretty quick and they’re going to be able to pick up on your avoidance related mechanisms or strategies pretty quick. And hopefully you would be sharing those as well as part of your treatment and therapy process about like, “When I freak out, I tend to shut down, I get real quiet, I’ll say that I’m okay, but I’m actually not okay,” right? So, they have to really build that relationship in order for people to kind of share those things. But most, you know, astute clinicians will be able to see avoidance a little bit and that really what we’re trying to do is walk, again, walk alongside someone and say that “You don’t have to avoid right now,” right? “So, you know, it seems like I’m observing that it looks like you’re experiencing something emotionally, but I can’t really read your mind exactly. Would you be willing to tell me a little bit more about what you’re feeling and put it into words?” which can be very, very hard to do when you’re feeling your emotions with great intensity and at a really inconvenient time, which is of course always when they come up right?
Melanie: Um, and you know, giving people permission to feel the emotions. Again, because they’ve probably been so used to and so conditioned to not to like, “No, I’m okay” or like, “Don’t let people see you break down, don’t let people see you upset, don’t let you—” But giving permission to feel, and reminding people and reassuring people that that feeling or that emotion will not break you, will not hurt you, will not last forever. But again, we’re also, you know, kind of of this belief a lot of times, mostly because we’ve never really tried it out any other way, that like “If I allow myself to feel this emotion and feel it fully, it’s just gonna keep going, and it’s just gonna get worse, and I’m going to spin out of control, and I’m just gonna always feel this way.” So, it’s easy to buy into that belief and kind of go with it when you’ve never tested out an alternative, which would actually be like, “Let’s see what happens when you allow yourself to your experience your emotions in a safe setting,” like an actual physically safe setting, as well as in an emotionally and like interpersonally relationally safe setting. So, you can see that your emotions rise, and your emotions fall, and I’m gonna sit here next to you and I’ll probably be sweaty and uncomfortable too, because it requires the clinician to kind of sit in their own discomfort, because most of us are empathic people and when you’re around people that are experiencing discomfort, you are too. Your central nervous system, your neurons, are saying “Ahh, this is uncomfortable too!” But if we can both sit through this together, we can work through it together and it won’t last forever, it won’t hurt you. And the more you allow yourself to do that, the less scary it is in the future to allow yourself to experience your emotions. So again, that looks a lot like sitting down on a bench in a hallway sometimes, walking, getting ready to go into a dining room, because usually getting ready to go into a mealtime is a pretty predictable time of heightened anxiety for folks in eating disorder treatment. So, it would look, could look like a conversation like that. It could look like a similar conversation like that in the dining room, kind of, kneeling down next to someone who was, kind of, had some goals, and they’re ready to come into this, and then they’re, you know, the food’s on their tray and they’re, you know, all their senses are going, they’re smelling things, there’s noise in the background, there’s all these kind of stimulation happening, which is like a recipe for, right, for anxiety to start to bubble up.
Melanie: Um, because sometimes our brain mixes up the signals and they’re like, “This is a threat, this is a bad situation.” But again, being able to say, “Your M.O., right, would be to get up and leave. If this were, if you were not in treatment, and there weren’t other expectations would probably be to get up and leave, right? Or just flat out refused to do this. We know that’s the way you’ve handled it in the past, and we’ve recognized that there are some issues with that. So, let’s try to do it differently. I’ll sit here with you and it will be okay.” But ultimately, you know, we want to empower the patient to make the choice to choose to eat the food or not eat the food and we’re not going to force anyone to do anything. But that I want to, you know, again support you and show you that you are capable. We’re trying to build someone’s belief in their own capacity to do difficult things.
Sam: Their confidence, their confidence that they can do hard things. And also, to realize, I think it’s so important, that the predictions we have about how things are going to turn out aren’t always true. Actually, they’re rarely true.
Melanie: Rarely true. Yeah, and then actually like, you know, in doing different, um, exposure exercises with folks where we have kind of a planned exposure ahead of time. One of the things that we do when we’re planning and setting up and there’s a ton of preparation and thoughtful around doing an exposure, no one gets surprised into doing it, but one of the things that we do is we say, “Okay, what do you think is gonna happen? What do you anticipate? What do you, what emotions are you going to be feeling? What are you gonna be feeling in your body? You’re gonna feel sweaty, you’re gonna feel jittery, are you gonna—is your stomach gonna be upset? Like, what do you think you’re gonna be feeling? What thoughts are going to be running through your head, like a freight train?” I want to hear everything. “What are all the, like, worst case scenario possibilities that you anticipate? Give it a number, like how bad do you think it’s gonna be on a scale of 0 to 10.” All of that, I want to get all that anticipation. Because on the back end, we want to then test out all of those assumptions. And you’re right, Sam, almost never is it as bad as what they think it’s gonna be. And it’s almost always like, “Oh, I mean it was hard, but it wasn’t as hard as I thought it was gonna be or I thought this part was gonna be harder than it actually was,” which is great, a great way to learn. Not only about that specific, whatever that exposure activity might be, but like to learn that like usually my worst assumptions about anything that I’m worried about usually don’t actually play out that way and I’m actually much more capable of handling uncomfortable, difficult, or anxiety provoking situations in a variety of contexts, not just in treatment, but like out in the real world. That’s kind of the beauty of like learning and growing through kind of exposing yourself to the things that you’ve typically run away from and avoided.
Sam: Right, well, when you face fear, it sort of generalizes to all fear.
Sam: You know, whether it’s fear with food or fear in a social situation, once you get that confidence that you can handle your own fear, it really opens up your whole world.
Melanie: Yeah, absolutely.
Ashley: Yeah, that’s, I was just thinking about that and thinking how our clients really, um, right, like perhaps they’re using that eating disorder to kind of not face that fear, right? Or it’s their soothing mechanism, it’s their coping mechanism. And so, they really might present with some low motivation, even if medical things are happening, if they’re medically compromised or even if anything psychologically is going on, they really might not want to change. How does the unified treatment model help them then kind of create motivation or get motivation when they do just don’t have any.
Sam: I think that’s such a good question, especially for parents out there who are thinking “My kid does not want treatment,” and how do you how do you navigate that treatment?
Melanie: Yeah, well it’s certainly one of the tougher things to navigate, but it’s also just kind of standard, right? Like, most people don’t start on any self-transformation journey 100% motivated, right?
Melanie: Like, whether it be “We’re going into treatment for an eating disorder” or “I’m gonna start managing my money better and using a budget” or, you know, what translated to any other thing, but that, you know, most human beings are ambivalent about change, whether it’s big change or small change. So, one, just starting at that place of recognizing and honoring that like ambivalence is actually normal and not a problem. It’s not a problem.
Sam: Right. And so stop judging it.
Ashley: I feel like that is so freeing. That is so nice to hear.
Melanie: Yeah, like and I mean we’re complicated human beings, we are so complicated often to our own detriment in that we, you know, feel we’re so complicated yet we want like everything to be all good or all bad, right? Or like I want, I have 100% motivation or I have 0% motivation. Well, what about all that stuff in between? Like what about like all the reasons that you want to change, which you may have a list of those, but you may also have very legitimate reasons to not want to change because change is scary, change is unknown. You know, so really, again, using that, um, building on the therapeutic relationship early on so that there’s a sense of, of trust and that, you know, we need the patient to feel cared for and seen and heard and understood. And I actually can’t think of a better way to kind of see, hear, and try to understand someone than to try to understand and honor the fact that they’re ambivalent and that as many reasons as there are for them to kind of embark on this journey and say, “Let’s do it.” There are also plenty of reasons that that make that difficult and scary and you don’t have to be 100% sure to start, right?
Ashley: Yeah, that’s so true.
Melanie: You can—I just need, I just need a sliver. I said when I’m working with like adolescents and I try to be a little silly, I’m like, “I only need like 1/1.5% to start and we’ll go from there.” You don’t have to be all in, because that’s also another kind of avoidant thing too, right? Like, “I have to be 100% motivated or this has to be 100% perfect in order for me to do it.” Well, nothing is like that. Nothing, nothing.
Sam: That’s true.
Melanie: Um, so really trying to be flexible with the way that we think about that. And again, honor and acknowledge that it’s been hard to change for a lot of reasons. You just showing up here doesn’t, like, erase all of that. So, let’s actually get through that. Let’s try to understand what it is that’s hard to change. That’s actually probably some of the work where we can uncover and understand how avoidance has been operating for someone, if we can, again, sit in that ambivalence and know that it’s okay to even just have a little bit of motivation to start.
Ashley: I just want to repeat that for everybody. It’s okay if motivation is low, right?
Sam: And it’s normal.
Ashley: It’s normal, right? It’s accepted. It’s normal. It’s okay.
Melanie: Yeah. Well, and like the old curmudgeonly pessimist in me when someone’s like, “I’m 100% motivated,” and I’m like, okay, I mean that’s great, but like—
Ashley: But are you?
Melanie: I mean again, it’s not because I don’t think people are, you know dishonest necessarily. We like to think that like, “Yeah, I’m all in” and you may be all in today, but like, you may not be as all in tomorrow because that’s life. Our emotions evolve and change, the situation involves and change, our desire and energy to put forth the hard work and fluctuate. That is normal and okay.
Ashley: Right, yes.
Sam: I think people are often surprised to discover, you know, they’re not motivated one day and then they wake up and they have a renewed sense of motivation and they didn’t realize motivation is up and down that way, right?
Ashley: It fluctuates.
Sam: Right, it fluctuates. And so I think you can get caught up telling yourself the story that because your motivation is low, it means this about me or it means this about my recovery, but really it just means that you’re normal if it goes up and down, right?
Melanie: Right. And that that’s why everyone’s journey is a little bit different too, right? Because everyone starts at a little bit of a different place and that again, that place kind of goes up and down. So, it might take longer to kind of make bigger steps, so we might have to start with smaller steps and we still need to celebrate them when they happen, right? And build that, you know, confidence, that self- efficacy, that like “I can do it.” But we can start as small as we need to start, any progress is good progress. Which is why I think also it’s hard to answer different questions that we get a lot of like, “How long is treatment, how many days do people need to stay?” How, you know—it’s impossible to kind of predict that because everyone’s experience, journey, mood, motivation changes and fluctuates and that is because we are complicated human beings.
Sam: Right, right. You know, you talk about how important it is for someone’s ambivalence to be fully seen, including all the pros and cons of change, all the pros and cons of staying the same. And I do think it’s so important to identify, “What was the eating disorder doing for you?” And I think many clients are surprised. It’s like, “you want to know that? I mean aren’t we supposed to just focus on all the bad stuff and help me get motivated?” But yeah, but the reality is that eating disorders serve a function, whether it’s some kind of internal function or a function within a family system, but one of the functions that comes up a lot is that, I hear clients say, “My eating disorder is who I am, and I don’t know who I am without it. This is my identity. You know, I’m you know, I’m the person who eats this way, I’m the person who exercises this way, I’m the person who looks this way in my friend group.” And so I’m wondering, with the U.T., how do we target, you know, helping someone find an identity outside of the eating disorder, because it comes up all the time.
Melanie: Yeah. Yeah, it does. And I mean, that’s just another example of how we’re kind of like bucking up against, like, what has become socially normative, in that we like create identities around these like caricatures of certain characteristics. Like, again, like “I’m the, I’m the vegan or I’m the clean eater, I’m, you know, I’m thinking about diet culture,” but it’s true and other things—
Melanie: Like, “I’m a leader, I’m a, I’m an athlete and I’m—”
Sam: “I’m a straight-A student!”
Melanie: I mean, every sitcom and made-for-TV movie and teen movie has dealt with that in some way or another, these identity struggles. And I think, you know, for any of us depending on where we kind of fall on our developmental timeline, I mean, that’s stuff that we should be working through. Like, these “Who am I?” sorts of questions. And we think about, you know, when eating disorders typically, but don’t always, because everyone is different, but typically develop in that, you know, adolescent stage a lot of times, not, again, not for everyone, but speaking in somewhat generalities, you know, that’s the time when developmentally the milestone is figuring out who you are, identity versus role confusion. So, it’s not surprising that your identity gets really disrupted and fused with the eating disorder at that time, which thus makes that diffusion much harder. But some of the strategies therapeutically certainly would be trying to identify and really capitalize on core values. Now, someone who has a fused identity with their eating disorder may not really know what their core values are.
Melanie: Which is why treatment is a really great place to explore that values exploration and understand the big picture. Like, “I know who I’ve been but who I want to be, like, what in this world is important to me?” And really being able to do some really pretty straightforward, and it’s amazing how many like, “AHA moments come” from this. But like, “Okay, this is what I want to be up here. I want to be someone that is open to new experiences and gives to the world,” and you know, all these like great aspirational things that we want to foster within ourselves and with other people, and then I would then say, “Okay, so how is the eating disorder? Is it moving you closer to that or is it moving you away from that?” Which seems pretty straightforward and it is, but a lot of times, that’s kind of the thing that really is like, “Oh, okay.” Or like, in what ways does holding onto the eating disorder get in the way of doing those things or what, what has gotten in the way of before. Because we talked a lot about earlier, like, how the eating disorder makes the life really small and if I’m saying that one of my values is to live and you know, a life that’s full of possibilities and creativity and flexibility. Well, that that is pretty explicitly hindered by living within the rules of an eating disorder, within a pretty narrow caricaturized identity of the girl that is a fitness guru and only eats perfectly raw, clean things or whatever. Um so, that sort of exploration I think is really important in therapy in general, but especially when we’re kind of trying to work with that motivation and take some forward moving steps, is really kind of emphasizing the values and where you want to be.
Ashley: Which sounds both beautiful and also very challenging, if you’ve maybe been set on a certain identity for so long, you know.
Melanie: Yeah, it requires creativity, it requires like imagining possibilities that you’ve not experienced before. Which again, can be fun and exciting work, but when you, again, lived in a narrow box for such a long time, which is why again, we don’t expect people to like recover on their own or like self-help their way through it because you need, you know, you need sounding boards, you need to hear from other people’s experiences who’ve had these experiences like you. Which is why I think group therapy is such a great outlet for that, whether it’s, you know, support group or more intensive group, things like that. Because it’s hard to see the possibilities when you haven’t seen them yet.
Sam: Right. I mean, some patients come into treatment—I’m sorry, Ashley.
Ashley: No, go ahead, Sam, yeah!
Sam: You know, it amazes me that when some patients come into treatment and they say “I never even knew anyone who had an eating disorder until I came here.” And how healing it is for them to realize they’re not alone and that ultimately they’re all struggling with some of the same core issues. You know, “Who am I? What kind of person do I want to be? How can I get my life back and get a bigger life because this small life is not working for me anymore?”
Melanie: Right. And what do I have to kind of offer and contribute that isn’t related to my weight, shape, size—
Sam: Food, weight, appearance…
Melanie: You know, whatever, or that caricaturized identity that had been created for me, like what do I have to offer otherwise? And usually people who are willing to do that exploration will find things way beyond they could have ever imagined, as far as the possibilities. Which again, that’s that part where as a clinician like, “Yeah this is why we do it!” Like, such a beautiful thing to see.
Sam: Yeah. The transformation, I mean, that’s the last stage in the U.T.
Melanie: Yeah, literally. Literally!
Sam: Yeah, it’s a really amazing experience to see that kind of growth.
Ashley: I was just thinking as you all were talking about the group work—so, one of the things that the Unified Treatment Model is kind of rooted in, well, one we definitely know David Barlow’s Unified Protocol Model. But we also have the tenants of the Relational Cultural Theory, and I’m curious if you could talk more about that, Melanie, just tell us more about what that is and what that does in the Unified Treatment Model and for our clients.
Melanie: Yeah, yeah. I’d love to talk about Relational Cultural Theory and Relational Cultural Therapy. Because for us as an organization, you know, our roots, we’re going back to roots here, but we’re talking about roots in a different way now. Our roots as an organization are really within a Relational Cultural Framework because at the time that Renfrew opened its doors in 1985, there really wasn’t a very well developed eating disorder field, so to speak. There weren’t journals, there wasn’t a ton of research associated with it, some things, but really not much. There wasn’t a lot of guidance for, like, how do you do this work.
Sam: A lot of it was just going into the hospital and just getting refed and released back to the world with no psychological work.
Melanie: No, and often using, you know, pretty like—um, like I know this is recording audio, but my face is making icky faces of like, you know, really unpleasant means of getting people to eat their food or be tubefed in a way that, that without their consent and stuff, which again, those days are long, long, long, long in the past and we need to make sure they stay in the past. But that, um, so relational cultural theory really kind of had its start in its heyday in the late 70s, early 80s when a group of kind of feminist thinkers, feminist psychology folks came together to really look the healing power of relationships. Because there was this kind of—and these were women that were doing this this, kind of innate like wisdom that they had as women knew that like we are all, regardless of our gender, relational creatures and that we live and grow in community and therefore we also need to heal in community as well. And that again, that can’t be done in isolation. So, Relational Cultural Theory evolved into Relational Cultural Therapy, which really informed what we did when we opened our doors in 1985 and still informs what we do now. So, the tenants, there are these, um, it’s called “Five Good Things in a Growth Fostering Relationship,” and man, if I haven’t used or overused the Five Good Things enough by now, I can’t— I use it in every aspect of my life. I’m like, “Have you heard the Five Good Things in a Growth Fostering Relationship?”
Melanie: “Let’s take a test!” And I so I will hit you with those right now. So, because it’s again, if—if healing growth happens in relationships, then we need to figure out how to create that and foster that within the therapeutic environment, meaning like one on one between clinician and client. And that’s not just again for the therapist, I’m talking psychiatry, nursing, dietitians. Which is why I have a job, is that I’m trying to make sure that again all of us kind of understand and know and are working in this direction of helping grow patients through growth fostering relationships. And the way that you know—here is like a litmus test for how do you know if you’re in a Growth Fostering Relationship. One, when you walk away from kind of spending time with that person, whether it’s virtually on Zoom—So, like, I’ll tell you right now this is going to pass the litmus test for me, is when I walk away from this hour, I’m gonna feel more zest. And I love that they used the word zest because it makes me want to, like, do something with my hands, and like—
Sam: Yes, I see, like, confetti.
Melanie: Yeah, like OOOH!
Melanie: But it just, it gives you more energy, right? But we can also think of different relationships or interactions that we may have that like the second you’re finished you do not necessarily feel zesty, you actually feel really drained. So, we can actually notice those differences. So, Growth Fostering Relationships have more zest, we walk away with a sense of greater worth and value which is always something that we’re trying to foster. I mean earlier when we’re talking about building confidence and self-efficacy and like, “I can do it, I can do hard things,” you don’t get to that place on your own. You get to that place because people walk alongside you and build you up and say “Yes, you can.”
Melanie: Let’s see, you know, it’s a greater sense of worth, a greater sense of clarity, meaning that through that relationship I understand myself better, which doesn’t always mean that I’m only getting positive feedback, like, “You’re awesome, keep going,” that’s good too. But also, like, “These are places that I find that you might be emotionally avoiding, right? And I want to help you not do that in that same way because we’ve already discovered that that’s kind of hurting you more than it’s helping you. So would you, would we be able to work on that together?” Which, again, gives me more better clarity about what’s going on. Each person walks away with a greater sense of productivity and action. And again, that “I-can-do-it-ness,” like me hanging out with you guys today, I feel like I’m more ready to do some things, right? And that the more that you feel connected in those relationships, which we can start, you know, kind of at the basics of like your therapist or your team that you’re meeting with one-on-one and these more kind of intensive relationships. But the more that you feel like you can connect and are growing and healing from that, the more desire you then have to repeat that in other relationships and peer relationships and family relationships, in a romantic relationship, you know any other type of relationship that it kind of builds a template that allows you to relate to people in a way that is more meaningful, healthier, or again, growth fostering. I can’t, I’ll say that over and over again because it kind of hits.
Ashley: That’s such a great phrase!
Melanie: I know! They did it, those relational cultural theorists really nailed it. So, if anyone is interested in learning more about Relational Cultural Theory or Therapy, a great resource is the International Center for Growth and Connection. That’s kind of the outgrowth they started at the Stone Center at Wellesley College, and then it evolved into the Jean Baker Miller Training Institute in Boston and now it’s evolved to the I.C.G.C. International Center for Growth and Connection. They have great website, lots of really good resources, and they also have like webinars and things like that. So, if anyone is interested in learning more, I’ve learned and grown so much from learning about and practicing and fumbling my way through trying to be to be those things for someone else, right? To bring that Growth Fostering Relational Environment for someone else.
Sam: It’s interesting that it started out from, you know, feminist thinkers, when really it applies across all genders.
Sam: I mean, we all heal in relationships. We all grow in Growth Fostering Relationships. It applies to everyone.
Melanie: It absolutely does. And the folks who were there in the late 70s will tell you that now, right? And, I mean, I think it speaks to kind of just the cultural shifts in our own understanding of the gender binary and that it’s not a binary. And that, again, that while there are gender differences in some ways for some people, sometimes, we really, when it comes down to it, there are some universal truths about human beings and that human beings grow in connection with other human beings.
Sam: We’re wired for it.
Melanie: Yeah. And we see the consequences when that need isn’t met. That deep, deep need that we all have when it’s not met through neglect, through abuse, through other, you know, dynamics that can just be so marginalizing and oppressing to people, that that’s when we see problems, right? Is when those needs aren’t met. So, we as clinicians are trying to fill that need and start in that place where if we can do this in this relationship, again, that Fifth Good Thing of that Growth Fostering Relationship is that it can create kind of that template and even that motivation for the patient to continue to try to do that with other relationships, not just with the therapist.
Ashley: Yeah, that is so great. I feel like so much work can be done that way than in the group room. And I’m thinking, like, not even all relationships have moments of just, you know, joy all the time. Like, there’s also hardship in relationships. There’s also some sad times, some angry times, right? And if we can learn how to kind of experience this within the group setting appropriately, right? Or respond appropriately with that, and we can build that core ego strength, like, how much greater will our relational experiences be in the outside world as we grow, you know? That’s just so great, yeah.
Melanie: Yeah, well on those, when thinking about it like in a group dynamic, right? Because there are groups that we run that are kind of within this framework, this Relational Cultural Framework, and it serves both purposes because, gain, growing relationally and growing in connection together, but at the same time in order to do that and having those kind of hard conversations as you mentioned, Ashley, those uncomfortable conversations, we’re growing our emotional tolerance and we’re practicing not avoiding those conversations. Like, how many people do you know, and again, myself included or some part of me, right? Like, I don’t like to be in conflict with people, I don’t like to have uncomfortable conversations, it makes my tummy feel icky. And, it’s a really necessary and important thing to do in life. As a partner, as a parent, as a friend, as a daughter, as a therapist, as a you know, whatever, you know kind of roles you’re in, that ability to sit in our discomfort, to be transparent, to be authentic, to be vulnerable is so powerful and, again, generalizes outside of that therapy room. So, it’s all kind of working together.
Sam: Well, and I think the surprising irony about those really, really uncomfortable, really uncomfortable conversations, is that those are the very things that bring us closer.
Melanie: For sure.
Sam: And I think we forget that sometimes. That repairing ruptures in relationships is what bonds us and strengthens the relationship essentially.
Melanie: Yeah, absolutely, absolutely. Which again, is like the—is emotional leaning in, it’s like that’s personified in that, right? Like, I’m leaning in to this difficult, emotional, vulnerable experience with you for the sake of growing, improving, and repairing a relationship.
Sam: Exactly, yeah, exactly. Melanie, this was wonderful. Thank you so much for being on our episode today. This is a really enriching conversation.
Ashley: I think so too. I’m curious, Melanie, before we go, if there’s just one thing, anything that you would like to share as you’re kind of sending off moment, what would you like to share with our listeners today? I know, big question.
Melanie: Well, I think learning. We’re never done learning and I think of therapy as learning more than anything else, but it’s learning through experiencing and experiencing fully. And I think a lot of times when we think about learning by doing and just do it, like, doing it robotically like getting through the thing, like getting through school and getting through the, you know, checklist of things. We don’t often grow from that experience quite the way as when we really go and dive in both feet and, like, “I’m learning by experiencing the good of it, the not so good of it, the hard parts, the fun parts,” you know. So, whether you’re listening as a therapist or as a client or patient or both, which a lot of us are both, right? You know, that whatever therapeutic process you’re entering into, again, therapeutic process could be informal, that I would encourage you to go into it with openness. Being willing to kind of lean into the experience and the emotions and know that, again, you’ll be okay, and you’ll probably grow from it. You’ll be better for it on the end, even—whether that experience is doing a podcast interview or—
Melanie: That’s my learning for the day.
Sam: I think we all grew a little today.
Ashley: I think so. Thank you so much, Melanie, we appreciate you being with us today and thank you listeners for being here too.
Ashley: Thank you for listening with us today on All Bodies. All Foods. presented by The Renfrew Center for Eating Disorders.
Sam: We’re looking forward to you joining us next time as we continue these conversations.
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