Welcome to Insight Mind Body Talk, a body-based mental health podcast.  

Today’s episode is an introduction to eating disorders; why they’re a real concern and a real illness, the impact an eating disorder has on a person, and strategies for coping and recovery.  

If you start to feel triggered by this information, please stop reading and, if you feel ready, pick up where you left off.  If you identify with any of this information, please reach out to a therapist, contact your doctor, or tell someone you trust that you need help. 

Our guest today is Alison Manley. Alison is a Licensed Professional Counselor, specializing in the treatment of eating disorders and trauma. She currently works at Northern Roots Therapy Center, a small private practice clinic in Madison, Wisconsin.  

She is trained in many therapeutic modalities, including acceptance and commitment therapy, cognitive behavioral therapy, eye movement desensitization and reprocessing, also known as EMDR, family-based treatment and has specialized training in working with individuals affected by childhood trauma and neglect. 

Ali aligns with the Health at Every Size principles and incorporates them into her work with her clients. Along with other aspects of intersectional social justice, she has worked in community mental health and private practice outpatient centers and has an extensive background and training in the treatment of eating disorders. 

Ali is currently in the process of earning her Certified Eating Disorder Specialist credential through the International Association of Eating Disorders Professionals. As someone with lived experience, recovering from an eating disorder, Ali is passionate that recovery is possible for her clients and their loved ones. 

Ali, thank you for being here today. Thank you, Jess. I’m so delighted to be here with you today.  

I’m so passionate about working with eating disorder recovery. It’s a very complex issue. Eating disorders have the highest morbidity and mortality rate of any mental illness. I believe that full recovery is possible, so I’m really excited to talk about this today. 

How would you explain what is happening when someone has an eating disorder? 

The simplest way to describe what an eating disorder is that it’s about someone’s relationship with food, their body, movement and themselves. Sometimes we get stuck on eating disorders being all about the food. While food and nourishment are an important aspect of our health, it’s also about our sense of self-worth, who we are, and all of the complicated things that happen when our relationship with food and body and movement and self is interrupted or disturbed. 

Who’s affected by eating disorders?  

Eating disorders aren’t a choice. They aren’t only effecting, cis-gender, heterosexual, affluent, thin, white women. In fact, eating disorders affect trans and gender non-conforming individuals at about four times the rate that we see with cis gender. Eating disorders don’t discriminate. They can affect someone of any age, any ethnicity and background. It’s also important to acknowledge that everyone experiences an eating disorder differently. People don’t fit well into neat little diagnostic boxes and it’s also common for someone to move across diagnosis.  

That said I can speak to some of the more common types of eating disorders. 

There’s anorexia nervosa, which is really characterized by restriction, limiting one’s food intake, having lots of rules and rigidity around food and movement. Also, being in an energy deficit, not taking in enough nourishment to adequately feed one’s body, often being at a weight that is below where one’s body is healthy. It’s important to acknowledge that is not just BMI. Someone can be in a quote unquote, higher BMI, and they can still be below the weight where their body is going to be healthiest, where they’re not going to be in an energy deficit. 

Then there’s bulimia nervosa which is often seen when someone experiences a loss of control with eating and binge eating, which we might describe as eating more food than one might normally at a meal or in a sitting and following that meal by using compensatory or purging behaviors could be vomiting, abuse of laxatives or diuretics, or over-exercising with the idea that the eating disorder wants someone to quote unquote undo. 

Binge eating has its own criteria as well, binge eating disorder, correct? Correct. Binge eating disorder is quite common. It is when an individual is often eating beyond the point of physical fullness or satiation, similarly to bulemia nervosa, there’s a loss of control and often a strong sense of guilt and shame. 

The difference between binge eating disorder and bulemia nervosa is that with binge eating disorder, often an individual isn’t following that binge with purging or compensating behaviors.  

I want to acknowledge that often there’s co-occurring mental health disorders with an eating disorder as well, for example, anxiety or depression. We can often see eating disorders as a way of trying to cope with underlying anxiety, depression, trauma, that’s showing up in the body or the mind. 

That is such a truth and so important to keep in mind if you’re someone that’s treating someone with an eating disorder, if you’re someone that’s suffering yourself, or if you’re a family member. It isn’t as simple as looking at the symptoms and finding fixes for them. There’s often a lot of doubt, a lot of pain and a lot more that’s coming up when we’re working on eating disorder recovery. 

Today is a brief introduction to this topic, we’ll have you back to explore specific aspects of eating disorders because they are so complex.  

What do you feel is the difference between eating for health and wellness versus shifting or evolving into an eating disorder? 

The difference between eating for health and wellness versus what might be an indication that someone’s starting to experience an eating disorder. One of the things that I look at is what is driving choices that we’re making with food and movement. 

If we think about the experience someone might have with an eating disorder, there can often be so much anxiety and fear that underlays the food choices or the movement that they’re participating in. One thing that I would first check in with is intention. What’s my intention. Am I doing this because this food is nourishing me? It helps me feel sustained. I enjoy it. Or am I choosing this food or this form of movement because I’m trying to change my body. I’m trying to shrink my body. I’m trying to feel good enough. 

We can think about eating disorders, disordered eating, and quote unquote normal or healthy eating on a continuum. I think about what’s the impact that someone’s experiencing with their relationship with food or their body or movement. For instance, are you going out on a run in the evening because you like the way that it helps you feel stronger, it helps you move your body and release some stress? I think that many of us would say that sounds like a fine choice.  

However, if you’re going on a run because there’s an inner critic that’s really yelling at you for the pizza that you ate that day and maybe you’re a friend has invited you to spend some time with them in the evening but you’re saying no to that because there’s so much fear and anxiety about gaining weight, that might be more what we’re talking about with disordered eating.  

We both believe it is essential to have a team. For example, a registered dietician who specializes in eating disorders or a physician who has experience treating eating disorders, because of physical health concerns.  

Because of their complexity, because there are so many different pieces going on with the body, the brain, relationships, anxiety, trauma, we really need a bare minimum therapist, dietician, and primary care provider on a treatment team. Other team members could be family members, psychiatrists, friends, coaches, occupational therapists. Knowing there are so many different pieces, we really need someone with specialty in a lot of those different areas for someone to get good care.  

Speaking about the dietitian piece specifically, many people with eating disorders hesitate at the idea of working with a dietician. They’ve got lots of food info and yet they still may have some quite rigid or unhealthy relationships with food. I like to think of dieticians at times as nutrition therapists, the person that’s saying eat this, don’t eat that. Working with a dietician allows someone to explore their beliefs about food, about weight and health to learn about fullness and hunger and metabolism. It’s not just having someone provide ‘here’s what you eat’, but really working on the why and the how, because our bodies are impacted by being in a state of nourishment or energy deficit. It’s really important to have a team member that’s helping someone out with that piece in their recovery. 

What exactly can happen to a body as a result of restricting food, purging, binge eating, or even just being hyper-focused on very specific, good foods or healthy foods. 

Eating disorders are not only emotional or mental health condition, but they impact our physical health. How so? 

I’ll draw from someone’s work that I’ve found so helpful. Dr. Jennifer Gaudiani is the author of the book, Sick Enough. It details the medical complications that can happen with an eating disorder and what happens to our bodies when eating disorder behaviors are affecting us. 

She describes what she likes to call the cave person brain. We’re biologically wired to defend ourselves against starvation. Historically, when our mammal brains and bodies were exposed to famine, that part of our brain responded to keep us alive. 

When we’re in an energy deficit, our body temperature can drop down because our brain and body don’t want to spend any extra calories or energy keeping our peripheral limbs warm. We’ll get cold hands and feet.  Also, a slowed heart rate because their body is really slowing down in response to starvation. We might see lower blood pressure and slowed digestion.  

If someone is really limiting their food intake, the digestive tract slows down, so when we eat, we get really full, really fast. We can get constipated and have lots of GI side effects. One other thing that I’ll mention is that we’re less playful. We’re less spontaneous. We become more rigid, more serious, and anxious, more obsessed with food. There just isn’t a capacity in the body to play because when we’re under threat, it’s about survival.  

Purging through vomiting, diuretics, laxatives are not effective ways to prevent the absorption of calories. Purging can also be really dangerous. It can cause electrolyte imbalance, which can put us at risk for cardiac problems, heart attack, chronic dehydration and kidney failure.  

Another consequence of under nourishment or restriction can be loss of bone density. This is particularly important for individuals in their teens or say early twenties. If someone who is able to menstruate is not getting their period as a result of restriction, that lowering of estrogen can mean that bone density is less protected. Someone that’s 18 could have the bone density of a 70-year-old. I want to highlight this because a lot of medical consequences of eating disorders can be reversed, but we cannot recover bone density. 

Let’s talk about negative body image. What would you suggest to help someone alleviate the critical voice or negative body image? 

I think, just calling out diet culture. Starting with what is diet culture? Where has this come from and where have you gotten these messages in the first place? 

We could say that it is a system of beliefs that equates thinness to health and weight loss to higher status, more happiness, or more love. It also demonizes certain foods and activities, even rest. Diet culture oppresses people who don’t fit the narrow view of beauty and health. 

Another way I bring this into work with clients is talking about body image on a continuum. If you imagine a timeline, on one end is body hate or body loathing. On the other side you have body positivity or body liberation. Then, there’s all of this in between space. 

We might think about this next place on the continuum as a place of body respect, where we are tolerating our bodies and taking care of them, even if we don’t like them. If I’m looking down at my tummy and there’s a voice that’s loudly saying that is not okay, I still make a choice to nourish myself.  Body respect is about how we treat our bodies even if we’re not in a place of liking how they look.  

Moving along the continuum, we’ve got body acceptance. Body acceptance, is a place of still having some conflicts with what I see in the mirror, but I’m not trying to change my body. 

Accepting that maybe my body needs to be here in order for me to recover from an eating disorder or to continue living a fulfilling life.  

We’ve got body appreciation after that. This is where we’re really expressing gratitude for what our bodies allow us to do. I might have appreciation that my arms can reach the top shelf of my cupboard, or my legs can carry me across the room. Body appreciation is honoring the function of our bodies and centering on our values and how appreciation for our bodies can allow us to further connect with them. 

Finally, we have body positivity, body liberation or body love. This is a place where we’re enjoying the body that we have. We’re not beating ourselves up, trying to change, or giving ourselves flack for changes that happen naturally with aging or pregnancy or what have you. We’re in a place of gratitude and compassion. We’re not internalizing cultural pressure to be perfect. We’re celebrating body diversity, that there is such a broad range of bodies that aren’t commonly depicted in the beauty ideal.  

Talking about body image on a continuum makes it much more reachable and accessible.  

We don’t have to constantly be in a place of loving every square inch of our body. It is okay to move up and down this continuum and we can be in a place of body respect or body neutrality. 

We don’t have to get to body love or liberation, and that also needs to be honored.  

I see eating disorder recovery as challenging our own inner critic or internalized oppressor. We can describe the eating disorder voice as the inner dialogue that’s going on and when we’re thinking about food. What am I going to eat? How much movement have I done?  

For many people, the eating disorder voice can start out with something as simple as, I’m going to try and eat a little bit healthier, or I’m going to try and move more. As someone gets further into their eating disorder that voice can become really loud, really unforgiving, and really mean.  

How does one begin to work with that voice?  

I draw from a few different models and approaches. I love bringing in parts work or IFS and exploring where did this part show up? What is its job? What might it be afraid of? I also bring in a model from Carolyn Costin’s work. She’s the author of Eight Keys to Recovery from an Eating Disorder. She talks about making a distinction between the eating disorder and the healthy self. And recognizing that an individual suffering from an eating disorder, isn’t their eating disorder. They are much more complicated as a person and that’s just a part of them. 

It reminds me of narrative therapy. The person is not the problem they’re experiencing. 

We can often over identify with these parts and start to internalize and believe that that critical voice is our truth. That it is who we are.  

For some people, eating disorder thoughts are ego-syntonic, what do you mean I have this eating disorder? For other people, it can be a relief to say, that’s not me, but I’m sick of this. 

It can help to start to pay attention to what that voice is saying. Maybe notice if there are certain themes. Be curious about where those rules have come from and work on strengthening your healthy self.  

In parts work, all parts are welcome. We consider that the eating disorder part has an important role and some really important things to say, that often go back to dealing with anxiety or attachment or trauma. We don’t want to demonize this part, but we also don’t want to get too enamored with it either. All of our parts have a positive intention. They’re almost always trying to bring safety and regulation and decrease distress. When we tell parts, they’re not wanted that doesn’t make them go away. It often creates a lot of internal conflict and distress. It’s not the part that has to go away, but maybe their method of trying to help. 

If we can be curious about this part, we can identify that eating disorder behaviors are a way of coping and we need ways to cope. We don’t want to take away someone’s coping skills and give them nothing in its place.  

If we’re working on strengthening someone’s healthy self, rather than reaching out to this eating disorder part, can we reach out to someone else? Can we practice that connection? That can be a path to healing. 

The mind-body connection is an extremely important aspect of eating disorder treatment and reintegrating mind and body and healing that relationship it can be transformative. 

What ways can a person begin to bridge the gap and heal that mind-body relationship?  

Eating disorders are dissociative in nature. It’s a way for us to disconnect from our bodies and live as much as possible in our heads with the rules and criticism. In some ways, that can mean we experience less pain, less distress. At the same time, we’re disconnected from ourselves, from our body and our feelings. Life gets gray and dull.  

One place we might start is by practicing awareness of our state. Am I hungry? How do I know? What might that tell me? We can build an understanding that our body can be a resource and a place of wisdom. Polyvagal Theory, watching the autonomic state shifts. Deb Dana said that the first step is noticing. When we can notice what’s happening in the system, we can engage with it versus it consuming us. Mindful awareness is often the first step.  

Another thing that comes to mind in healing the relationship between the mind and body is the concept of intuitive eating. Intuitive eating is a way of approaching food choices and eating that focuses on honoring our hunger and our fullness cues, rather than what our head or eating disorder voice or diet culture are saying. It may not be the starting place but more of an end goal.  

How does a person start to begin to reconnect with their body through movement? 

Principles from Health at Every Size can be really helpful. Health at Every Size or HAES is a non-diet paradigm that focuses on health and instead of diet or weight. With HAES we’re understanding that fat is not equal to unhealthy, thin is not equal to healthy and weight is not equated with success or worth or health or status. 

One of the HAES principles is life enhancing movement. What movement is someone able to engage in with their body? Will this movement help with my feelings about myself? With my physical health? A good guide can be focusing on how does it feel when you engage in that movement rather than how many reps did I do? How many calories did I burn? Am I feeling embodied? Am I enjoying this? That’s what I hope to see with someone that’s really in a place of joyful movement or life enhancing movement, as opposed to exercise that might be more connected to an eating disorder rule or behavior. We’re looking at movement as a place of joy and connection to oneself.  

A lot of body positivity or liberation goes back to the sixties and fat activism. There is a lot of labor that’s been done to fight for this liberation. We’re really trying to honor the experiences of all sorts of individuals; those that have been oppressed, that are differently abled, that are in queer bodies and black and brown bodies. Actively challenging the belief that we can only like or love our bodies if we’re aligning with the ideal that’s really rooted in white supremacy, capitalism, and ableism is central to the healing of our body image.  

Thank you for all the wisdom you have shared with us today. This has been a pleasure.