S5 E4: Understanding Disordered Eating w/ Dr. Aubrey Carpenter

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• EPISODE RESOURCES

  Dr. Carpenter’s practice in Vermont:

  https://www.ittakesavillagevermont.com/

  JAMA paper about rise in EDs during COVID pandemic: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2798255

  NEDA website: https://www.nationaleatingdisorders.org/

  NEDA toolkits: https://www.nationaleatingdisorders.org/toolkits/

  MEDA website: https://www.medainc.org/

  JVN podcast on Getting Curious: https://podcasts.apple.com/us/podcast/how-f%24-d-up-is-fatphobia-with-professor-sabrina-strings/id1068563276?i=1000562241844

  HAES movement: https://asdah.org/haes/

  Jonathan Haidt's Anxious Generation: https://jonathanhaidt.com/anxious-generation/

  Kids Eat in Color - Kids Eat in Color

  Jennifer Anderson MSPH, RDN | Kids Eat in Color (@kids.eat.in.color) • Instagram photos and videos

  Growth Charts - Homepage (cdc.gov)

  Radically Open Dialectical Behavior Therapy | Fact Sheet - ABCT - Association for Behavioral and Cognitive Therapies

• EPISODE TAKEAWAYS

  • Our relationship with food and body/self-image can be complicated. A discussion about these topics may not even be openly discussed, making it even more complicated, as people can have a hard time talking about this sensitive topic.

  • Challenges with disordered eating are not specific to “Western Culture”.

  • Eating disorders are often comorbid (co-existing) with other mental health conditions like anxiety, OCD, mood disorders/depression, and sometimes even trauma.

  • The DSM-5-TR is a diagnostic manual for the mental health profession to identify if eating patterns and consequences constitute a diagnosis, as well as a significant amount of distress and impairment to functioning. 

  • However, you don’t have to have a diagnostic disorder to have had negative or distressing experiences with food intake and self/body-image. Our relationship to food exists on a spectrum…ranging from picking eating, food allergies, to other issues relative to self/body-image.

  • Athletes may not have been taught specifically about how to understand food intake and how to fuel their body, given the physical demands of their sport.

  • Body Mass Index (BMI), which segregates body weight into categories, can be an inaccurate way of understanding if eating patterns constitute an eating disorder, especially for children. It only takes into account height and weight, without other factors that contribute to weight and the growth curve of a child’s weight. Instead, the BMI percentile is used to understand a ‘growth curve’ of a child to determine what is considered a ‘healthy’ and stable growth pattern.

  • When children grow up and go to college, they may not be followed for physical health visits, which can prevent the identification of changes in weight and growth.

  • The ‘thin ideal’ is only one example of something that can influence an eating disorder, although there are many versions of idealized aesthetics that can contribute. Dissonance-based interventions help adolescents to argue against the ‘thin ideal’ and other ideals that are not necessarily accurate, healthy, or helpful to growing youth. This intervention has been shown to reduce risk for eating disorders.

  • There are various questions that can be asked by a professional to understand the ‘function’ of a behavior, like using exercise, eating patterns, or even something like using a waist trainer, in order to identify if there is a distorted belief or perception about body image and desire for weight changes.

  • Social media can certainly fuel ‘ideals’ that are far-fetched and unrealistic and unhelpful/unhealthy. It can contribute to comparison. The developing brain, as is the case for adolescents, may not be able to think critically about the images they see on social media. 

  • Youth may also get information from illegitimate sources on topics like nutrition, etc. that can fuel false beliefs and distorted perceptions. It is important to vet the professional who is sharing information about the body.

  • Eating disorders may start with good intentions, like wanting to get healthy, despite becoming unhealthy.

  • Perfectionism cuts across a lot of mental health conditions, including eating disorders. Some research suggests that low self-esteem and difficulty tolerating mood states may contribute to perfectionism, which in turn contributes to disordered eating patterns (Jones et al., 2020). 

  • Perfectionism can be a cultural norm. However, perfectionism can also be conceptualized as a form of creating a sense of safety and an inherent desire to feel accepted by others. Radically Open DBT is a therapy that has been developed for helping individuals who are overly- or under-uncontrolled in their behaviors, which relates to eating disorders. 

  • Similarly, Internal Family Systems (IFS) Therapy helps people to identify the way in which we develop coping mechanisms to survive and get through very hard life circumstances and pain, which turn into unhealthy and maladaptive patterns, and then gradually developing new, more adaptive coping mechanisms.

  • Challenges with eating disorders can be very private and can make it difficult to address the underlying issues, psychological pain, and factors that are contributing to the disordered eating.

  • It can take time for individuals to develop a healthy, genuine, and positive sense of self in a more holistic sense rather than an intense desire for one specific thing, like body image, to ‘make or break’ how someone feels about themselves. It often happens within an authentic, caring, and supportive relationship.

  • We can learn how to accept imperfections we have and see ourselves more holistically in terms of all aspects of ourselves that make us who we are.

  • When children grow up and go off to college, they may lose the structure that comes with meal preparation and consistency.

  • Restrictive eating can contribute to even more rigid thinking (inflexible thinking), which can make it difficult to address the disordered eating and its causes.

  • Eating disorders are often the ‘tip of the iceberg’ in terms of psychological challenges the person is experiencing. And so, the treatment for an eating disorder for one person may warrant a different approach than another person, depending on which factors are contributing to the disordered eating in the first place. For instance, some may have co-occurring OCD, others may have fallen into unhealthy habits out of peer pressure, while others may require treatment for underlying trauma or issues within family systems. 

  • Family-based treatments help parents to regain a grasp on helping their child to feed with parental support. It has a lot of evidence as an effective treatment; however, it may also or may be more important to target something else to support the child. The NEDA website has a ton of information that can guide you about treatment options.

  • It helps when therapists can explain their approach and collaborate with the patient and family around understanding the rationale of the approach, to monitor progress, and to gather feedback from the patient. A strong therapeutic relationship is important.

  • It helps to have a registered dietician, particularly for moderate to severe eating disorders, to understand the nutritional and chemical aspects of food as it pertains to what the individual needs in terms of total energy and food intake. This can be especially important for athletes who are exerting a lot of energy on a daily basis.

• TRANSCRIPTION

  Gerald Reid  00:09

  Welcome back to season five of the Reid Connect-ED podcast. Today's topic is all about food intake and body image. It's an interesting topic for sure. On the one hand, we consume food to survive, we need food to survive. Food, not only calories, but also the nutrients provide the necessary energy required for all of our organs, including our brain. On the other hand, for various psychological, sociological and even biological reasons, we develop a relationship with food that can get, well, complicated in our field of mental health. It’s not uncommon to work with individuals whose relationship with food, which is oftentimes but not always, connected to body image and self-image, involves a lot of emotional distress. It could lead to difficulties and limitations with day-to-day functioning, it could lead to physiological issues. It can contribute to challenges within relationships and issues with eating. What we call in our field, eating disorders are not specific to Western culture, either shown to exist across all cultures in their own ways. Influences for how we relate with food and body image can be very complex and contextual. Furthermore, one's relationship with food is often something that is not openly discussed or even understood, which complicates matters even further without going into detail right now, since we're going to get into more specific examples within this interview, I just want to set the stage by framing this conversation today in a way that does not feel shaming, does not feel judgmental, but rather, we hope this conversation is simply educational in nature. Of course, as we disclose in the outro of every podcast, this is not a substitute for professional care, and also, there may be different opinions in the field about certain topics. If you want to learn more about the topics discussed today pertaining to you or someone you know, please seek out a trained professional in mental or physical health by getting referrals from your primary care physician, a local hospital, a place of employment or school, your insurance company or wherever, professional referrals are available to you. Additionally, the ideas and perspectives shared today are not representative of all the ideas and perspectives within our field.

  So today, we're joined by my friend and colleague, Dr. Aubrey Carpenter. Dr. Aubrey Carpenter is a licensed clinical psychologist who has spent over a decade working as a pediatric psychologist, educator and researcher in Child Mental Health and parenting support. She completed her PhD in Clinical Psychology at Boston University, where she focused her clinical work and research on child anxiety disorders and the benefits of family involvement in child mental health care. Dr. Carpenter discovered her love for pediatric psychology during her rotations at Hasbro Children's Hospital and Rhode Island hospital, where she had her first introduction to adolescent eating disorders and how serious they can be. Dr. Carpenter completed her pre doctoral internship at Boston Children's Hospital and her post doctoral fellowship at Massachusetts General Hospital before returning to her home state of Vermont to raise her family. Dr. Carpenter spent two years working in an outpatient mental health clinic and three years working at UVM Medical Center and the adolescent eating disorders clinic. During that time, the influence of eating disorders nationwide skyrocketed as a result of the pandemic and the related impact on child and adolescent mental health, she became involved in state level advocacy that led to increased funding for eating disorder programming and training for Vermont providers, including a free of cost training for 100 mental health providers in the state of Vermont that is actually occurring today.

  Dr. Carpenter recently pivoted to start a private practice called it takes a village, which is by the way, ItTakesAVillageVermont.com where she is primarily seeing parents and caregivers in need of support, after seeing firsthand that behind the Youth Mental Health Crisis is a widespread community of parents doing their best with limited resources, she continues to see some adolescents with eating disorders, and is very passionate about supporting their families through the recovery process. Aubrey, we are so, so happy to see you here today and to have a conversation about this very important topic that may not get discussed openly in the public, but certainly is very important and significant and impacts a lot of people, whether it's yourself, the audience, or someone that you know in various aspects of society. So very happy to see you again. And also, we were trying to figure out how long it's been since we crossed paths, physically, since the pandemic. And as you mentioned, you know, we did cross paths at Boston University a long, long time ago. And I think our calculations are right. It's been about eight years. Believe it or not.

  Dr. Aubrey Carpenter  04:43

  I know I am so excited to be here to catch up and talk about this very important topic that's near and dear to my heart, and I'm happy to talk at some point too, just about kind of how I got into this work, because Jerry, as you mentioned, we both started out treating kids and teenagers with anxiety, OCD and related challenges, and in this very roundabout way, this eating disorder work has kind of brought me back to that population, as I realized how many kids have co-occurring challenges, and how often disordered eating can kind of go along with some of those things, or maybe serve as a coping mechanism for managing OCD and anxiety. So it feels very full circle that we are connecting again and able to bring some light to this very important issue.

  Gerald Reid  05:25

  Yeah, well, I love what you just said, Aubrey, because you know, mental health is complex, and usually things could be things can overlap, and things could be interrelated, as you're mentioning. So what a great example about how you kind of see the commonalities between different mental health conditions and eating disorders as well. And as we know, in the field comorbidity, which means multiple diagnosis or multiple mental health challenges, it's usually more common than not. It's more common than not.

  So, Aubrey, where do you want to start? You know, let's kind of, you know, the audience may or may not have been exposed to information about this topic. What do you feel like is a good kind of overview about, you know, understanding challenges with eating and body image.

  Dr. Aubrey Carpenter  06:03

  Yeah, I'm happy just to, you know, talk a little bit about, how do we even define eating disorders, which, in my experience, I think even that question and that topic can sometimes be really anxiety provoking and sometimes triggering for folks, because it can feel like this, either taboo topic that, you know, we just don't know how to talk about. I think there is a shared understanding that many of our family and friends and people that we know and work with and interact with them the day to day may be struggling with this. And I think oftentimes there's kind of a fear of saying the wrong thing, kind of like with grief, you know, sometimes we don't know what to say, so we just don't say anything at all, which, unfortunately the problem.

  So I'm happy to kind of start with thinking about how I define it. And you know, you did a great job in the bio of just talking about how, or in the intro, of talking about how sometimes some of these topics can be triggering. So I always like to just give a little bit of a trigger warning that I will try my hardest not to be triggering. But sometimes there may be certain topics or stories or details that might feel difficult to listen to. So just for everyone, take the time that you need. Feel free to turn the volume down, take a pause. Fast forward 30 seconds, whatever you need to do to come back to it.

  But yeah, I would start with just thinking about how we define it. I think you know, if anyone is a regular follower of Jerry and Alexis podcast, then they will probably have heard of the DSM before. So, you know, we as mental health providers often use the fancy word is the Diagnostic and Statistical Manual, which is, you know, kind of the place where providers go to have some shared understanding of what constitutes a disorder, what constitutes a problem.

  But I very much see everything is on a dimension. Everything's on a spectrum. So I think all of us understand what anxiety is. All of us understand what worry might feel like. We all understand what mood fluctuations can look like. So you don't have to have a diagnosable disorder to have had some experience with emotions, and so the question often becomes, when does it become a problem? When is it causing distress and interference and disordered eating is no different. So it's one of those things where we all might have certain kind of growth edges when it comes to eating. Maybe we have very specific preferences. Maybe we were the kid that was the picky eater, and our parents still talk about how difficult it was to feed us growing up, maybe we have food allergies and so we have some maybe adaptive heightened anxiety around potential allergens and cross contamination. So there's many reasons that we might all have our food stuff before we even get into body image and the societal contributions that can often get into that. And then athletes, I think, are often up against a huge challenge when it comes to thinking about how to fuel their bodies. And one of the reasons I really love working with teenagers with disordered eating, especially athletes. Here in Vermont, we have some really incredible young athletes up here, skiers and mountain bikers and all of the things is no one has ever taught them how to fuel their bodies for the very intense workouts that they're being asked to do. And it's not because anyone had any sort of malicious intent, but their kids, a lot of the time, you know, they've eaten the way that their families eat. And sometimes things can start out with good intentions and kind of go awry.

  So all of that's to say disordered eating is very common. And when we think about when do we get to the point of actually calling it an eating disorder, we really need to see some sort of significant interference or significant problem that's causing there are a number of different types of eating disorders that I won't get into in detail, but some of the disorders are what we would call restrictive eating disorders, so things like anorexia nervosa and avoidant and restrictive food intake disorder, otherwise known as arfid, where oftentimes there is either a weight loss component to it, so the person has lost a significant amount of weight, they might be struggling to grow so. For younger kids in particular, they might not have lost any weight, but they've continued to grow in height and essentially haven't kind of caught up. So when you look at their growth curve, instead of continuing to go up on the curve, there seems to be like a plateau or sometimes even a dive down in really serious cases. And so some fluctuations are totally normal, but that is just one of the data points that we as providers are integrating when we're thinking about, is this a problem that might benefit from some intervention? And if so, what does that intervention look like?

  Gerald Reid  10:31

  Yeah, Aubrey, you know, to branch off what you just said, because I know that BMI Body Mass Index historically has been something that has been used to identify if this is kind of a problem within the body weight where it's not enough food intake to maintain what your body needs. And you know, you had mentioned to me long, long time ago that they're trying to find, as you said, the growth curve is maybe a better indicator of is this person on the right trajectory for the amount of weight and food intake that they need to nurse their body based on their body, their individual body. Can you say a little bit about that, that shift, or, you know what that means for people just to understand that better?

  Dr. Aubrey Carpenter  11:09

  Absolutely. Yeah. I think anyone who's ever met me knows that I am not a fan of the BMI, nor is anyone that works in the world of eating disorders. It is outdated, not helpful. There's actually a fantastic podcast by Jonathan Van Ness, if anyone follows his getting curious podcast about fat phobia and weight bias, and they go into the history of the BMI, and it's just so interesting and so fascinating. So for kids, we are never actually looking at the BMI itself in the way that most of us probably understand the BMI, where we have these kind of number ranges that correspond to certain kind of definitions or degrees of health, such as a normal weight category or underweight or obese or very obese. So for kids, BMI is not actually accurate, so we are using the BMI percentile. So for example, you might have a kid who is totally in the healthy weight range, but if you use that BMI range, they're going to look like they're very underweight. So it isn't even a metric that makes any sense.

  Gerald Reid  12:07

  Why would that be the case? I'll be just for the listener, like as that example, like that particular type of.

  Dr. Aubrey Carpenter  12:11

  Yeah. So essentially, the BMI, the history of it is, it's much more intended for use with adults, and has not caught up to the more science backed definitions of what health actually includes. So weight on the scale is one data point. But as you probably know, we can be living in larger bodies and be in perfect health. We can have, you know, an excellent resting heart rate, no cholesterol issues, you know, no high blood pressure, no risk for heart disease, none of those things. So there's going to be a genetics component, there's going to be lifestyle components, there's going to be health related concern components. And so number on the scale should never be the only thing that we are using. And unfortunately, BMI is just that. It just takes into account your weight and height and no other details. So for kids and teenagers, we use what's called the BMI of percentiles, and that is what the growth curves are. So if you can picture a growth curve, you can actually go download one for free on the CDC website. They have growth curves for boys and girls in the zero to two range, and then for children older than two, and you can see all the different curves. So for example, you might have 25th percentile or 50th percentile or 75th percentile, and there is a very wide range around what is considered to be a kind of healthy range to be in.

  So what we are really tracking, what pediatricians always track at their well visit, starting at the very first newborn visit, is where is this child falling on the curve, and are they remaining stable? So I'll use an example of my own child. So I've had three kids. They were all right around the same weight at birth, and for whatever reason, one of them has just trended on a much lower percentile. And so if he were to continue falling off the curve, that would probably raise the alarm bell, alarm bells. But he's a great eater. He has no interfering issues. He's just a little guy. He's just at the 16th percentile all the time. And so the pediatrician has continued to feel more and more comfortable and satisfied with seeing that. That's just where he seems to be leveling out. For whatever reason, he's probably just going to be a little bit smaller than my other two. He eats the same foods, eats the same amount of food per day, has had, you know, no other kind of health differences.

  So there's just some natural variation. We're not supposed to all look the same as human beings. So it's really about, you know, is that person following a curve? And, you know, is it consistent? And again, there's going to be kind of little jumps up and down over time, as there is with all of us. So there may be an illness where we lose our appetite for a week or two. Maybe somebody gets covid or the flu, and we would hope that eventually their hunger cues would come back and they would eventually kind of level off. Another example might be kids who have gross spurs, where maybe they jump in height and. Then their weight kind of follows and catches up with them. I think we can all probably picture the awkward phase that all of us went through around those middle schools are all lanky and you know, those those growth cards, are just going to look a little bit different when you're comparing height and weight, and that's totally expected and totally normative.

  So I actually think for kids and teenagers, especially when you have the close pediatrician involvement that kids often have with their annual well visits. You know, we have a pretty good eye on these things. So often what we see happen is, you know, kids go off to college, or teenagers and young adults go off to college or move out of the home, or, you know, all of a sudden they're responsible for their own PCP visits. And in shocking news, they're not getting made and, you know, nobody's actually kind of laid eyes on them for a while. And that's where sometimes we can see that maybe there were some changes, whether it was intentional weight loss or not, that we just haven't had the close follow up to be able to kind of keep track of. So I think it starts to get a little bit harder to track in adulthood, because we don't have the expected growth, but we do have lifestyle changes that might contribute to weight going up and down, and you know, that's just essentially what human bodies are supposed to do. They're supposed to fluctuate.

  Alexis Reid  16:10

  You know, I'm just sitting back here listening and just in awe. You both are just so amazing at describing and talking about all this. And you know, immediately our minds go to thinking about teenagers and young people in making comparisons and what they see and what they think is, quote, unquote normal or what they're supposed to look like. But as you're talking more, Aubrey, I'm actually thinking more about the parents and their perspective, and I'm so glad you shared you know, the story of your own children and how one of your children just is a little bit smaller than the others. But in this world of you know, especially with athletics, there's a lot of comparison. In the famous quote of thief is comparison is the thief of joy.

  A lot of parents that we interact with and we hear stories about are really making comparisons of their kids to, you know, where they see them going in the future, instead of where they are right in front of them. And I know we'll get into this more, but I just wanted to make this point of considering, you know, every child, every human, is going to be a little bit different, and it's going to have their own path and journey, and we need to keep all of the research in perspective. And I always say this about research, that it's only as helpful as we use it, and sometimes we can make it say what we want to do, and we have to be super mindful of how we use that in context of our growing children, that sometimes it's okay being okay, and exactly where you are. And I think it's just a really important point that I'm glad you shared, with respect to your own children, that you know we're all going to be a little bit different. We all have different different needs at different times, and that's okay

  Dr. Aubrey Carpenter  17:46

  Yeah, yeah, absolutely. And I think that's why I started doing more parent work in recent years, is because, you know, I could do as many sessions with kids and teenagers as I wanted to, but parents are the ones having to do the really hard work on the front lines, behind the scenes, right? So the, you know, teenager, the kid, comes in for one visit per week, and then the parent is asked to do daily support of the meal plan or the coping strategies or safety monitoring, whatever it might be. And there's just so much that goes into that, and that makes it hard.

  So I think Alexis, to your point, you know the fear of the unknown, and, you know, not being able to necessarily predict how our kids are going to do. It's both the scariest part of parenting and the biggest gift. I think, for me personally, Parenthood has just been such a self-growth opportunity, but a little bit overwhelming at times, and even today, as you guys know, I was navigating, you know, child illnesses all week, and I was like, am I going to be able to make it to the podcast recording today? I don't know my best. And so thank goodness it worked out, and we had contingency plans. And everybody's healthy now, which is great, but so much of that parental skill set that is required when we're thinking about, how do we support our kids, whether it's an eating disorder or something else totally

  Alexis Reid  19:01

  We always say it's the most important and probably one of the most challenging jobs anybody could ever have. And also, you know, I, you know, I'm not an expert by any means in any of this, but I've studied a lot of it just through my own journey in staying healthy and feeling well for what I am in myself. And I'm learning so much from just listening to you both go back and forth and to dive into all this. And to your point, Aubrey, you know we don't know what we don't know. And as a parent, faced with a child who might be experiencing an eating challenge or disorder, it's probably one of the most scary things in the world, because you don't know you only know what you know. So I'm so glad you're doing this work to support the families you're working with. Thank you.

  Dr. Aubrey Carpenter  19:43

  Yeah, well, and I tell parents all the time that we have a biological drive as parents to feed our young like that is built into our DNA, and that is so triggering when our young will not eat for whatever reason, whether it's challenge. Challenge or a medical event that has required a limited diet, for whatever reason, it's very, very challenging to watch our kids struggle to feed. The breastfeeding journey for a lot of parents, is a really emotional one, because when there are challenges that are unexpected, it can just really throw you and can really contribute to postpartum anxiety and depression, that's not your fault. So when I think, you know, feeding issues and the parent involvement, I really think about this as starting from the beginning, even you know, during the pregnancy phase, like you're already thinking about, how do I get this child the nourishment they need, and what are the things that are going to get in the way of it? So I just always like to validate that for parents, it's supposed to feel hard. It's supposed to feel it means that you're an attuned parent. That's actually a really good sign. If it's feeling hard doesn't, doesn't always feel that way on the day to day, but it's a good sign.

  Alexis Reid  20:50

  Beautifully said.

  Gerald Reid  20:51

  That's great, and it really goes into how we help anybody in therapy. You know your emotions are telling you something, pay attention to them and use them as information to make decisions. What a great reframe and just amazing what you're doing. You know, you went back in the beginning and you said something about, you know, what is considered healthy, or kind of, when does it get into the unhealthy range? And to what Alexis and you are both saying, it's hard to know. You know, the unknown is scary. And you know, our mind can, you know, make things up in our head about what to expect, or what's normal, what's not, or, you know, what we should be doing to help. And you know, if we look at the research on adolescents, it's actually very common for adolescents, even without an eating disorder, to worry about their weight and to be concerned about how their body looks, especially during this identity development stage. And you know, as we're talking about kind of influences, one of the influences is comparison, and also, you know, wanting this thin ideal. And I kind of want to get into this a little bit. I know it's not the only thing, but as we're talking about how everyone's different, and we should celebrate people being different and unique, and everybody is as they are, and they can love themselves as they are, and we can love people for who they are.

  You know, I remember reading this research. It's actually in our social psychology class long, long time ago, and and it was about dissonance based interventions been shown to prevent eating disorders, and it's had some effectiveness in preventing and the idea behind it is actually to to argue, to help people around this age, adolescents, to argue against this thin ideal that everybody has to be super, super thin, and to argue against why. That's not accurate. It's not helpful. It's not healthy. It's not something we want. And to actually help to adolescents to argue against it has been shown to actually, you know, prevent is preventative. It kind of buffers against that, that urge, or that social pressure to fit into that, that mold that may not be healthy for them. And so, guess, just making a point here, but want to talk a little bit about that, you know, the influences of eating disorders, because I think, you know, there's a lot of maybe stigma. There could be even assumptions about what causes it or what contributes to it rather, you know, I think we try to avoid using the word cause mental health issues, because it kind of blames one person or another. It's really more what contributes to it. There's a lot of factors that contribute. Because maybe you can say a little bit about that.

  Dr. Aubrey Carpenter  23:13

  Yeah, absolutely, yeah. And I'll, you know, kind of offer some expanded terminology too, like we often think about the term the thin ideal, but it's not even just the thin ideal anymore. So I actually work with a lot of boys, which I really enjoy working with, because they don't have nearly as many visible spaces as girls. Have to be able to acknowledge and address some of the body image components, and for them, it's rarely about being thin, it's often muscle mass and strength and having six pack abs. And, you know, whatever it might be. I was actually just meeting with a male client earlier this morning, and we were going through this book. There's this fantastic book that we can maybe link in the show notes, called being you. And it's a book about body image for boys, specifically geared towards boys. So it's very visual. There's lots of kind of client anecdotes, and really brings it to life. It talks about puberty. So, you know, it really just covers all of the different kind of aspects that play into this. So, you know, it's not always necessarily the thin ideal.

  When the Kardashians came along, all of a sudden, it became about the curvy ideal. But all of a sudden, you know that thin ideal is not even a thing anymore. You know, one of the points I think you had wondered about when we were kind of prepping for this earlier, was thinking about like, what are some of the trends that have come up? And, you know, that would be a good example of where eating disorder focused therapists have had to really keep up with some of the trends so that we know what to ask about. Because, you know, historically, we might have only asked about, you know, is this person intentionally trying to restrict the amount of nourishment or intake that they might have? Are there any kind of purging behaviors that come along with it? But all of a sudden, we're asking about, if you've ever used waste trainers before, and that's something that comes up, like getting a sense of what the workout. Are, what the function behind the workouts are? Are they aiming for a particular esthetic and particular muscle groups, or is it about, you know, the mental health benefits of a good cardio workout, and can we take a rest day when we're sick? So there's just so much that goes into the interviewing and the assessment process, into not only just understanding, has this risen to a level of concern. But how do we understand what the relationship with it is and kind of where the motivation is?

  So the book that I was referencing that I was looking through this morning used to the example of Mark Wahlberg, who, apparently, when he was training for one of his movies to give a little Boston shout out, beloved Mark Wahlberg, who doesn't love Mark and Mark, He was apparently eating 10 to 12 meals per day to be able fuel for the gym workouts that he required to be able to essentially get the physical physique that's necessary. So it really just, you know, highlights like, not only does no one have time for this in the real world, but it's not sustainable and it's not real life. So, you know, when we see these characters on the movie screen, they are not trying to influence youth in a negative way. If anything, I just love the celebrities that are able to speak out and talk about the, you know, kind of preparation that might go into being ready for a particular role. Just to highlight that it's it's not normal, it's not sustainable, you know, it's not supposed to look that way.

  But the developing brain who is attuned towards comparison as you make a good point about Jerry, is not going to be thinking about it that way. They're not going to see all of the behind the scenes prep and have the thought, well, that doesn't seem realistic. That doesn't look like a body type that anybody else around me, has we just kind of subconsciously, you know, weave it into whatever the ideal might be. And that's where I think it's just so interesting to work with youth and young adults that have kind of fallen into disordered eating. Because I really always like to emphasize this is not your fault. We are not suggesting that you set out to, you know, have this get to the point that it got to. Oftentimes it starts out with a really good intentions, and the person might feel like they are really just trying to be healthy. And you know, oftentimes they're really kind of shocked and frustrated and outraged that anybody would suggest that this is problematic behavior, because as far as sources that they've been exposed to, this is perfectly healthy, if not recommended. So a lot of the intervention, you know, can kind of include that dismiss based like, let's actually evaluate this. Let's actually ask some questions, but also making sure that our sources are coming from legitimate places. I've had so many teenagers who have told me that their kind of meal preferences or their eating plans have come from Pinterest, and I'm always like, this is the place you're supposed to go to for design inspo, not the place you're supposed to go to to learn how much protein should be on your plate. Really, just kind of evaluating, like, are these science backed resources, or am I, you know, potentially operating off of information that's just actually not that accurate or not that helpful?

  Alexis Reid  27:59

  Oh, it's too real. And it's not just the teenagers. There's a lot of adults that are getting their inspiration and information from social media. It's really unbelievable. And not it is believable actually, because a lot of the information is portrayed as if it is science backed and science based, and sometimes doctors sharing information and and I think the root of things,

  Dr. Aubrey Carpenter  28:20

  Sometimes it is, good stuff not to interrupt. But, you know, I don't want to knock it all, but I think it is about evaluating the resource totally.

  Alexis Reid  28:26

  Totally. But in addition, in addition to that, I think one of the things that all three of us are big proponents of is really getting to know yourself and your own needs, rather than just looking at the masses and seeing what everybody's saying that you should be doing. Because I think there's so many fads and trends. But I think the most important thing you know, just to pull out one of the themes that you're both are talking about, and it's a theme on the show all the time, is that you really need to investigate your own needs and really get to learn more about yourself. I think that's what the journey is, being a human here on this planet. But especially if you're noticing that something doesn't jive well for you, or something is feeling a little bit off in whatever aspect of your life you're in,

  Gerald Reid  29:09

  Absolutely and you know. And speaking of that, of kind of knowing yourself, I digged into the literature a little bit. And when we have these episodes, sometimes, I just want to see, is there something that's interesting that we can bring up? And it was about adolescence, and it was looking at adolescent eating disorders, and kind of looked at this idea of perfectionism. And I know perfectionism tends to coincide with eating disorders among pretty much a lot, almost not every but many mental health conditions, you can see perfectionism kind of crop up and be an influence. And the article actually suggested that low self esteem and mood intolerance, meaning having a hard time tolerating different mood states, and low self esteem may have actually contributed to the perfectionism in the first place that kind of contributes, eventually, to the eating disorder. And so I do want to talk a little bit about the psychological aspects. You know, we did talk about the ideals out there that could be influenced in different ways. But, you know, can you talk a little bit about the kind of the psychological aspects of perfectionism, or other aspects that you have seen, you know, working in your practice? Because I do feel like we're kind of circling around the idea of loving yourself and accepting yourself feeling good about yourself, and certainly with eating disorders, it can get complicated, because the less you eat, it can actually make it hard to want to eat, as you know, maybe you can talk more about so there is kind of more of a biological component that can make it hard, other than just kind of learning to love and accept yourself. But I do want you to hear a little bit about your perspective on that with all the work you've done.

  Dr. Aubrey Carpenter  30:39

  Yeah, oh my gosh, I could talk about perfectionism all day long.

  Alexis Reid  30:45

  You're in good company for that.

  Dr. Aubrey Carpenter  30:47

  I know it's just so good, and it, again, speaks to the idea that, like, it's not our fault, right? Like we inherit these things from society. So one of the interventions for eating disorders that I have gotten really into, it's probably my favorite intervention to use, but it's relatively new. Is called radically open DBT, which is a spin off on DBT. Maybe you guys have heard of it. It is just and it's so great because it's intended for adults, and they're now scaling down to adolescents. It's developed by Thomas Lynch with kind of input from Marshall Linehan. So it really kind of presents this idea of a bell curve where, you know, a lot of us may be at more one side of the curve versus the other, somewhere in the middle, but just this idea that the way that we cope might be more overly controlled. So it might be an overly controlled coping style, which we tend to see more so with perfectionism, you know, needing things nice and neat and tidy, and we like things done on time, and we like predictability and rules and structure, and we don't do well when things are unstructured and loose and unpredictable really throws us for a loop. So ro DBT was developed to be helpful for that side of the curve. So oftentimes we might see things like perfectionism, OCD, anorexia, obsessive compulsive personality disorders, even autism, OCD versus the other side of the bell curve is what DBT is intended to be really helpful, which is more so the under controlled copers. So those might be the folks that have a really hard time experiencing strong emotions, and for whatever reason, you know, maybe they've had a lot of trauma in their lives, have a very real reason to want to avoid sitting with really difficult emotions. So they might be more likely to struggle with suppressing the urge to act on a feeling, so whether it be self harm or substance use or challenges with interpersonal communication and effective communication.

  So I often think about it as, you know, perfectionism is a kind of culturally sanctioned norm that we tend to see, but RO DBT talks about it as it's essentially all about safety at the end of the day. And they do such a good job of incorporating evolutionary psychology, which I love using in my work, because they think it, again, just normalizes that this stuff isn't all just coming out of nowhere, like, there's like, a very real, maybe it's theory based, but a very real series of understandings around why we might do the things that we do. So they use this idea of, like, you know, we are tribal animals. We are supposed to hunt and gather together in communities. There's a reason building communities feel so good. There's a reason that support groups can sometimes feel even more helpful than individual therapy, depending types of supports you're navigating and perfectionism allows us to kind of maintain our status in the in group. So if we are not making mistakes, we are less likely to get kicked out of the group. If we are, you know, following the group norms, we are more likely to be accepted by the village, accepted by the tribe, versus be the one kind of on the outskirts of the tribe, which I just think is so fascinating. So I think for a number of us, we use perfectionism as a coping strategy.

  Sometimes, you know, whether we realize it or not, and so we do tend to see it sometimes go along with certain presentations and certain things. And that's often how I see disordered eating pop up, which is, you know, it's really a coping strategy at the end of the day that might help someone feel like, okay, well, at least I'm, you know, fitting in with what I perceive the group norms to be, or at least I'm not, you know, in this particular body size or range that I perceive as being at risk of being bullied or something like that. So I do think, like with everything, it starts out with really good intentions, but I think having that understanding can really help us let go of some of the shame that comes along with it, that, again, you know, we might be kind of engaged in these behaviors, whether it's perfectionistic thinking or certain behaviors or disordered eating, whatever it might be, because we just want to be accepted and included and unconditionally loved at the end of the day, like that is the human condition in a nutshell.

  I guess the last thing I'll say about perfectionism too is there's a fantastic Instagram account that I make all of my patients follow, or strongly recommend that they all follow. Perfectionism is a component. Her name is Dr. Jen Douglas, and her handle is @DrJenOfficial, and she's a Stanford trained psychologist who specializes in perfectionism. And she just shares so much great content. And, you know, just kind of talks about her work in, you know, the Palo Alto area, and you know, the number of very successful professionals that she works with that can just really, really struggle with this crippling perfectionism. So she just does a great job. She even does things like intentionally put spelling errors into her posts, essentially exposure therapy for her followers, and then kind of normalizes it and talks about it. So she's just a great kind of resource, I think, for anybody starting to be curious about how perfectionism might show up in their lives, and if it might be more harmful than helpful.

  Alexis Reid  35:53

  It’s so funny, and I'm gonna, I'm gonna jump in here, because you guys are doing such a good job. I feel like there's not much I can even say to add to this conversation, but I will add that I do a lot of work around perfectionism, especially with the clients I work with, and one of the things that I actually do is I make mistakes on purpose all the time, and I point them out. And oftentimes I've been having this conversation a lot lately with high schoolers, especially where they're like, Well, I just have to do all these things, and I have to do it this way, and I'm like, in no world are you going to look back on your high school career and feel bad about this one thing that you're fixating on right now? I'm like, that's just not a thing that you're going to be thinking about. I'm like, I'm hoping that you can find a way to kind of release some of the tension that you're experiencing right now, to be able to experience the joy and the presence that you have right here in this moment, and even reflecting on how you're doing and what's going on in your world, and I think we miss so much of that. So I'm so glad you brought up those examples.

  So perfectionism is so important. And Jerry and I often talk, both in practice and in the podcast about controlling the controllables. And as we're having this conversation, I'm reminded of how much folks who do have trouble with eating disorders are often trying to control the thing they feel like they have control over. And I wonder if we can kind of go down that path a little bit, because it toes the line of understanding the mental health challenges some of the external factors that young people are often faced with, and from an executive function perspective, you know, go to your point before when you see these different examples in Hollywood or on social media or elsewhere, where you think that's an ideal and you're not making the connection like this isn't reality, or there's so much that went into getting to this phase or point of what you look like.

  You know, these these kids, their frontal lobes aren't fully developed yet for them to be able to see outside of the present moment or what they are kind of focusing in on. So I would love for you both to kind of share a little bit more of your experiences with some of these individuals who, again, might comorbidly have OCD and eating disorders, and try to tease that apart for some of the listeners who maybe haven't experienced what that's like, either in their personal lives or in the lives of somebody that they might see experiencing some of those different concerns and issues that come up in their lives.

  Gerald Reid  38:13

  Yeah, I mean, I can speak kind of broadly on that, as we talking about controlling things to feel more in control when life feels out of control. And, you know, like a theory, like internal family systems theory, basically suggests a lot of mental health challenges. Are what you said, Aubrey, you know, we go through things that make us vulnerable, and then we try to compensate, and it could help us to survive those challenges, but they become outdated. They become no longer adaptive in the long run. And part of, you know, therapy is kind of undoing and finding replacements for the ways that we cope, essentially.

  So a lot of therapies kind of revolve around that idea in their own ways. But, you know, I think as we're talking about how to help someone, you know, an adolescent, part of this, you know, is thoughts about yourself are usually private. You know, there may be signs like, Oh, they're looking in the mirror a lot, or they're comparing themselves a lot. But the actual thoughts, the actual things, the beliefs that are going on in the adolescent's head of the child's head, are rarely private, and so one of the, I think the most important thing, or one of the really essential things that could happen in therapy, is for the for the child to feel comfortable, to really open up and not feel embarrassed, ashamed, or feel like they have to keep those things private, because when you do that, you know a process, a process can unfold to understand it better, because the pain or the suffering and the challenges people in their life may not even know what they are.

  You know that could be happening private. They could be bullied, bullied in private. They could have interpersonal issues with their friends, with their family, with siblings, with anybody, really things that maybe be glossed over that don't really, you know, aren't acknowledged as real pain, that they're going through a real struggle. And so really, I love therapy, when things could be open and you can really explore and understand what it's like to be that person in a very individualized way to say, Okay, I. Wow. Like, maybe we didn't really even acknowledge that this has been a struggle for you, and when you put things into context, Wow, that really could have been something that you had a hard time coping with, and this could be part of that coping mechanism.

  And then we talked about fitting in is definitely one, too. And then, you know, begin to challenge those thoughts, those beliefs in a cognitive way, and also help the person to express and experience their emotions, which is important part regulate the emotions. And I think in the long term, and this could take a long time, in my experience, in my practice, is really helping someone to internalize a healthy sense of self. Could take time, you know, and I think in this idea of like, mental health has to be fixed quickly. Certainly, food intake does have to happen quickly. You told you taught me that, Aubrey, you know, when it's severe, right?

  When someone really needs food intake to survive, because it could become dangerous in certain levels and severity. Severity is important. You know, we don't want to this is not a one size fits all conversation, but when it's not at that level, right? You know, really feeling good about yourself, it's not a straight line, and it's not a clear indication about how to do that for someone, but certainly it's almost always going to happen within, within a very positive, caring understanding authentic relationship. And therapy is a good place for that to start, and hopefully it can happen with other people, but that's a long that that is a process to help someone to truly, authentically understand themselves, love themselves, feel good about themselves, so that that coping mechanism doesn't have to happen, because when you don't like yourself, when you hate yourself, which, you know happens a lot for these kids, you know, everything's a threat because you're constantly on edge because everything doesn't feel right, because you're walking around if you don't like yourself, you're basically walking around with something you don't like, Right? So, you know, I think that's kind of a deeper thing that you know could be hard to work through, but isn't very important. In my opinion, the people I've worked with who have gotten better over the long run really start to like themselves and appreciate who they are on a holistic level, rather than this one thing is going to make or break who I am as a person.

  Dr. Aubrey Carpenter  41:59

  Absolutely, there's such great points, Jerry and I'm like jotting down all these notes right in front of me, because I have so many kind of things that come to mind that I think are just helpful for the listeners to maybe keep in mind. So kind of three comments in response to that, if that's okay, I think you just did such a nice pivot into thinking about why we often strive for body neutrality now instead of body positivity. So you see that, you know, the body positivity movement was something that was supposed to be on the pedestal for everyone to strive for, just this idea that we're supposed to love everything about ourselves, and I think, providers and and people, human beings, you know, have learned that this is not actually necessarily realistic, like it's very common and very normal to all have something that we may not love and certain things that we may feel really proud of.

  So the goal isn't to love our physical bodies entirely and not feel like there are any flaws, but rather to devalue the physical appearance as where our self worth comes from. So I just think about it like a pie chart, right? Like our physical appearance is one of the things that makes us who we are, our physical health and well being might be one of the things that makes us who we are, but there's so much more to it. It's our sense of humor, it's our intellect, it's our you know, kindness as a friend. How nice are we to our neighbors? You know, all of these different things that go into making up our identity. And to your point about, like, adolescent identity development like this is just a hotspot for teenagers to try and figure out, like, who am I really? So, you know, the goal is really to, you know, kind of not discount the fact that some body dissatisfaction may be normal, but to have that kind of bear less responsibility or less contribution towards how we're actually thinking about ourselves.

  Gerald Reid  43:43

  Real quick, real quick. Aubrey, and it's kind of like being the metaphor would be like being a parent, right? Sometimes your children may irritate you, but you still love them.

  Dr. Aubrey Carpenter  43:52

  Yes, exactly. Yeah, it's not going to be a perfect experience, and the imperfection is actually what can make it so meaningful.

  Alexis Reid  44:01

  Yes, the dialectic holds true.

  Dr. Aubrey Carpenter  44:03

  It all comes back to the dialectic. I know, yeah, and, you know, I often think about, you know, a metaphor that I often use to help teach people about how eating disorders can sometimes serve a purpose. You know, it's, it's totally unique for everyone, but it can be this life raft where, you know, we're going to cling to the life raft when things feel totally turbulent and out of control. And that's really what we saw happen during the covid 19 pandemic, where eating disorders just absolutely spiked during this time, where all of a sudden, everybody's doing a remote school. There's no structured mealtimes anymore. Everybody's kind of fending for themselves with a daily routine, hunger cues are kind of going out the window because we're eating and sleeping at random times, and we seek to control what we don't have control over. And so there were a lot of reasons that I think eating disorders spiked during the pandemic.

  There's a great paper by the team at Boston Children's Hospital in Journal of the American Medical Association that really kind of looked at, I think it was 16 different hospitals across the country at their inpatient and outpatient rates of teenagers that taught treatment for eating disorders. And the graph is just so worth the download. We can link to it in the show notes, because it just shows this massive spike. But what's interesting is the spike happened way later. So it was, you know, late 2020 to into 2021 and essentially what happened is we kind of lost track of all these kids. Because, if you remember, we stopped doing in person medical visits for months and months and months. So everybody's well visits were rescheduled or transitioned to zoom. Nobody was getting the typical weight and height check that they had been getting used to so we kind of lost all these kids until all of a sudden, you know, they were really struggling and, you know, kind of presenting in a much more significant state of illness than if we had been able to catch them earlier.

  So I think it really speaks to that idea that, like, nobody's going to let go of that life raft if they are in a stormy sea and unable to swim, they need to have those other skills ready to be independent, ideally feeling like a confident swimmer, but at bare minimum, being able to tread water before they're ever going to want to give up this coping tool. So, you know, I always tell teenagers all the time like, I'm not going to ask you to change your behavior. I'm going to ask you to try and understand the function behind these behaviors and then figure out what else do we need to, you know, make you feeling like you're more in control, or feeling like the the people in your life, whether that's families or friends or whatever it might be, are able to support you around whatever you might need, so that you don't feel like you have to kind of be bearing all of this by yourself.

  And the book The Anxious Generation, by John Haidt, you guys might have heard of. He's been quite a press tour. He's everywhere right now. You know, one of the really interesting things that he talks about is that kids, oftentimes, when they're presented with the opportunity to be without cell phones during the day at school, they will often say yes please, but when it's up to on their own, that's going to feel really hard. So I think again, kind of speaks to the idea of going against the grain is never going to feel realistic, because, again, we just want to be part of the inner group. We want to be part of the tribe. But I think teenagers are really smart. They know when something may be serving them well or not serving them well, whether it's phone use or social media use.

  And you know when it comes to disordered eating and some of the things that can play into it, I meet teenagers all the time that are like, Yeah, this isn't helpful. Like, someone actually told me the other day they used chat GPT to look at the certain amount of intake that they had gotten for the day, which is apparently a feature that it has. And they had said, like, you know, on the one hand, like, this could be really helpful. It can help me be aware of did I eat enough? Like, did I do what I was supposed to do from what my dietitian told me to do? On the other hand, it's just another way to track what's happening. You know, your parents may or may not be aware that you're doing that. So again, I think you know, just always trying to find ways to normalize and move the needle on to society for kids and teenagers and adults, especially so that they don't have to feel like they're, you know, totally swimming upstream, or, you know, feeling like they have to go against the grade, because that's always going to feel really hard to do. And individual therapy is a great space to do that, because it is that trusted relationship in that safe space. But still, you have to find the therapist in the first place and make sure that they understand and have training in disordered eating, so that they are giving you, you know, the most evidence based approaches to talking about how to handle it sensitively.

  Alexis Reid  48:27

  I wanted to jump in for a second too, Aubrey, because I'm thinking, as you're talking about that, you know, the teenagers during covid 19, and how that traumatic experience and the disruption to the structure and the child's day really kind of opened up opportunities for this to kind of emerge as as an issue that we saw on probably a global level. I would imagine. I don't know the statistics on it.

  But I'm also thinking about that relative to a student who is transitioning into college being independent for the first time, it's really difficult for a lot of students who are transitioning to college again, going back to the prefrontal cortex that's not fully developed, they might not be in tune with their hunger cues and understanding when to go to sleep and the things that they totally need as they're transitioning from being in a highly structured environment in high school to going to college, and I'm thinking of all These students I work with who infrequently eat three meals a day. They often are eating foods that their parents would never feed them, or it's almost like they're in survival mode to just kind of get through their day a lot of times and you know, part of my work, though I'm not a nutritionist, is to bring that to their awareness, to help them understand how structures and routines and building in meals to their day is an important piece to the puzzle of how they can become healthy, independent, functioning adults in life.

  But a lot of times they miss that, and I'm just talking about students that I work with who may come from means. And there's also other populations that don't even have access to food, that might be in this scarcity mindset, where they are really just trying to survive, where there might be these unidentified issues that are emerging. You know, we're talking about finding the right mental health care and finding the right services and support. And some people might not even know that any of this is available, or if that this is even happening in their world. And I wonder, you know, how would you both speak to that? You know, this podcast is a platform to share information freely for people who might not have access to information before. So I'm wondering, like, what you would share and say, and this might be a tough question and answer to those who might not even notice this is happening, or have any barometer or metrics to even recognize that this is an issue or concern that they should be more aware of.

  Dr. Aubrey Carpenter  50:54

  Yeah. I mean, I will say I can't say enough good things about both the National Eating Disorders Association, NEDA and the multi service Eating Disorders Association, which is actually a Boston based group, NEDA, is absolutely incredible. It's a national resource that's available even like I went on the website this morning, just to kind of refresh my memory on some certain statistics, and they recently redone the website. There is just a resource in there for everything. There's a toolkit for parents that talks about different levels of care and how you might know when someone might be kind of trending from being appropriate to outpatient to needing higher level of care. There are resources around, what does a dietitian do? What's the difference between a registered dietitian and a nutritionist, which you know can sometimes overlap, but can sometimes also look very different. There is a coach's toolkit. If I could have every single coach incorporate snack into their [toolkit] I would be the happiest lady in the world, too.

  Alexis Reid  51:51

  I talk about this all the time,

  Dr. Aubrey Carpenter  51:55

  Yeah, building in fuel to the day so that you don't have to be the one. Again, it's back to that in group, out group, like, who wants to be the one to raise the hand and ask for the extra snack? You know, for some people, that's no problem, but for other people that might feel really scary and really hard and they go without and it's just a whole, you know, kind of domino effect. But there is also a toolkit for educators. There's a toolkit for those in the workplace, like, what to do, if you know you might notice someone struggling you're not quite sure what to do or say, they have a 24/7 chat line that you can access. There are resources for just all of the statistics around, like, how do I even make sense of this and understand this? It talks about all of the different co-occurring challenges that might come up. So you might not necessarily view yourself as someone with disordered eating, but you might know that you have, for example, type one diabetes, and you are just living on your own as a college freshman taking care of your illness. And you know, the daily needs of that illness every single day, and sometimes eating can start to get a little wonky, because we've never had to fully manage it on our own. You know, it talks about gender identity and sexuality in the context of disordered eating. And what might we do if we're noticing that maybe we're trying to change our body to fit with our identified gender identity? You know, maybe we don't want as many curves and so we are, you know, reducing our intake to have more of the body type that we want, but at the expense of our physical health. 

  So there's just so many angles around this that, you know, I think oftentimes we don't necessarily see it as disordered eating, or think of it as an eating disorder, but there can just be so many reasons that it can go awry. So NEDA is amazing, and then Meta or meta, I'm not entirely sure how you pronounce it, actually, but the multi service Eating Disorders Association, they have a fantastic directory for finding therapists in the greater Boston area. So one of my colleagues actually at Boston Children's Hospital, said that they routinely use that provider directory because it's just all kind of vetted eating disorder focused therapists, so really just helping people get connected to resources so that they can work out. Like, is this a real challenge? Maybe this isn't that big of a deal, but I still need a little bit of support anyway. Jerry, I don't know if you see this, but I oftentimes feel that people don't come into therapy until it's it's a big problem with a capital B, capital P, it just kind of normalizes this idea that, you know, we don't have to wait until things are really significant to open up a conversation about it, like we can meet with someone and say, Yeah, I don't think this is a huge deal. But, like, here's some of the things that I'm noticing. You know, I'd be interested in learning more about it, maybe doing some tracking, and, you know, getting a sense of how the emotions and the behaviors are all coming together. So it's huge. And I guess the last point related to that, you know, Alexis, I'm thinking about different college students, as you mentioned, where, you know, they're living on their own for the first time, just the cultural component that can come up too with, you know, when you're eating away at home for the first time and you don't have access to preferred foods, and it's all new foods that you're used to. I've had a number of patients who really, really sadly, were, you know, kind of labeled as essentially a restrictive eating disorder case, and that was 100% not what it was. They just did not like the foods that were available. I remember back to my first year in college. I was very freaked out by all of the meat options, and I quickly became a vegetarian, and quickly realized, like, Okay, I need to learn how to be a vegetarian, because this is something that, you know, just kind of quickly came upon me, and then again, later on, realized, okay, I actually do want to incorporate meat. How do I do that in a way that actually fits with my meal plan, you know, in the dorm? So I think there's just so many layers to these transition times where we can fall into changes in our eating patterns. And you know, it's nobody's fault. There's no shame around it. It's not intentionally problematic or malicious at all, but it can quickly go awry if we don't have the resources to help us kind of figure out, how do we nourish our bodies, especially if you're more active too. So all of a sudden, you're walking across campus all the time. You know your energy out is much more significant than it might have been if you lived in a place at home where you were driving everywhere. So you need more energy for that. 

  Alexis Reid  56:10

  Oh my gosh, I'm totally I'm thinking from like, an intentional concern, from athletes who maybe were high functioning athletes in high school who were no longer playing sports in college, making that transition right, being in tune with all that? 

  Gerald Reid  56:25

  Yeah, definitely. And there is some; I’m going to relate to the cognitive functioning too. And Aubrey, you can maybe comment on that, but I remember seeing some literature that you know restricting food can actually make you less cognitively flexible, meaning that you could become more rigid in how you're thinking, and your ability to kind of think outside the box, solve problems flexibly, which are very adaptive skills to probably solve the very problem that maybe contributed to the eating disorder in the first place. So it's kind of a self reinforcing cycle. You know, you become less open minded, and then you become more rigid, which could feed into the eating disorder itself as well.

  Dr. Aubrey Carpenter  57:02

  Absolutely, I'm so glad you brought that up, Jerry, I was so fascinated, you know, when I first learned about this years ago, because it does, it makes the problem a little bit harder to see as a problem, because we are so focused on the day to day routines and behaviors and rigidity. And that's why sometimes, you know, some of the medications that might be used if someone is really struggling. And, you know, has really gotten to that point where the rigid thinking might be pretty intense. There may be some different psychiatric medications that can be prescribed that really help with that rigid thinking. And so, you know, oftentimes having either a psychiatrist involved in your care or consulting to the primary care physician can be really helpful because, you know, can help you work through some of that early blocks. And one of the interesting things that I thought this is totally a theory, but again, in that kind of vein of using evolutionary psychology to help justify why we why we might do some of these things. One of the ideas brought up was that if we were in hunter gatherer times and we were essentially starving, it would be very advantageous to get fixated on every little berry and every little animal sound in the bushes, you know, as potential signs of a predator. So some really interesting ways to think about, like if we are in true starvation mode, that rigid thinking might actually be really helpful, because we get so focused on food for survival or the lack thereof, for survival. But I think also speaks to the fact that, like, that's when, you know, you're probably in that danger zone. And again, the NEDA parent toolkit does a really good job of laying out all of the different criteria that think about when higher level of care might be needed. You know, especially if you kind of gotten to that point where we really need to get some nourishment in you so that you can start flexibly thinking again, and, you know, some of the kind of higher order cognitive processes that come with healing and learning and just kind of sustained recovery just can't happen when you're totally malnourished.

  Gerald Reid  58:54

  Yeah, definitely. I mean, it reminds me, in some ways, of, you know, people struggling with addiction, right, that the problem itself becomes its own problem. And kind of, the problem itself could be about something else that contributed to it, right? And you start drinking, using drugs, and the withdrawal and the dependence becomes its own problem. And, you know, so certainly, it's a multifaceted challenge, you know, and I think that your work and the people out in the field are doing such a great job of trying to understand it in that type of way and to treat it in a way that's going to be effective.

  Dr. Aubrey Carpenter  59:24

  Yeah, well, and I think that speaks to one of the other points we wanted to get to, which is, how do you even think about what their therapeutic approach to start with? And, you know, how do we kind of reconcile this idea that there are so many different therapeutic approaches? I for one, have found that there are so many more approaches in terms of what people use to treat eating disorders than I've experienced with a lot of my other former work with anxiety and OCD and depression. And I think part of that is because the eating disorder is often the tip of the iceberg, and it's what's underneath that really helps us think about, you know, what does this person need to move through it? It. So if this is a coping strategy to manage trauma and years of not being in touch with our body and not being in touch with our emotions, that might warrant a very different approach than, you know, the teenager that kind of fell into this for the wrong reasons, or, you know, the 15 to 18% of people with eating disorders that have co occurring OCD, you know, there's lots of kind of different approaches to thinking about it, so I love RO-DBT, but there's some really good evidence base for exposure therapy. Even using DBT sometimes. CBT, there's something called family based treatment, which we often use, or might use. It's considered to be the first line treatment of choice for kids and adolescents in particular. But the kind of controversial aspect of it is it's really focused on parents, kind of taking over control of the food intake, and then scaffolding in the skills and the family systems work towards the end. So some people don't love it and are not the first to go to it, because it doesn't get into the higher level of kind of thinking that might be coming along with some of the deeper aspects of healing, such as, how do we get here in the first place? I think it's the most beautiful intervention to watch, because you take parents that feel so defeated and so scared and so overwhelmed by how sick their child has gotten, and they become so empowered, and they learn distress tolerance skills. They learn how to openly communicate. They learn how to set boundaries with their kids. And, you know, we essentially externalize the eating disorder and say, you know, like, this is not your child at this point, like it's the eating disorder that we are all on a team against your child, included. Like your child is the star of the show. You know, the captain of the team in many ways, but they need some help. They can't do this on their own, so I think it's a beautiful intervention, but it does require some very specific training. So I just want to kind of normalize that, that you know if and if you're in treatment right now for an eating disorder, and you're receiving another form of care that I didn't just mention, that might be totally fine. There are so many kind of ways to come about this, but there should be an open conversation with your provider around, how did we decide what our approach is? And I think if you ask your provider, you know, what are we doing? What is the approach that we're taking right now? And they can't tell you, I think that's a really good kind of conversation or opener to think about like, is this the right fit? Is this something that, you know, we need to have a little more structure happening here? I think some people like to have, you know, a much more open ended approach. But sometimes that may not necessarily be what's warranted. There may be a more skills based approach that can be really useful too. NEDA covers all of this, so go to the NEDA website.

  Gerald Reid  1:02:38

  Yeah, we'll have that in the show notes. And, you know, it goes back to what, for me, the most important aspect of being a therapist is, is conceptualization. You know, what are the driving forces? And what are the ways that you can address those driving forces? And sometimes it takes time to understand what they are, right? So that thoughtfulness is very important. And as you said, you know, therapy should be an open conversation. You know, it shouldn't be that the therapist has, you know, is kind of like a closed black box and not sharing what their thought process is, what the process I say this all the time to my patients. I'm like, you know, this is how I'm thinking about it. Let's continue to work on this and see you know how this relates. And you tell me, because, like, you also want to have them collaborate. The more they're involved, right? The more they can explore things that they may have never explored. To realize, oh, how many times have you worked with the patient? They're like, Oh, I never realized that until we started talking about it. It happens all the time, right?

  Dr. Aubrey Carpenter  1:03:54

  Yeah, those power dynamics are so real. I'm so glad you're naming that too. Like, you know, we really want our clients to remember like they are the box at the end of the day, they are hiring us as the therapist to provide a service, and we should be able to describe what that service is, and we may not be able to easily predict exactly where it's going, or, you know what it's going to be as new information comes to light. And you know, there's that dynamic process that comes about, but I think just making that space for clients to feel really heard and especially empowered in medical settings, because with eating disorders, there's so much medical intervention often that comes with it, and there can be some really well intentioned providers that might accidentally trigger the person, but they don't feel like they can say anything. So for example, you might have what we call blind weights, where oftentimes folks are getting weekly weight checks, and oftentimes the recommendation is that the patient doesn't know what the weight is, if it's going to be so triggering that it's going to send them backwards. So if they find out that they are gaining weight and they're still feeling ambivalent about gaining weight, that can be really hard. But if that's not done carefully and handled really well, or. Patient accidentally sees the weight because, you know, the nurse forgot, or, you know, the doctor forgot, or left the screen open on the computer. That was something I always, you know had to learn to be very careful about that can be really, really hard. And if the person doesn't feel comfortable opening up to about it, it's it's just really tricky. It can be like, two steps forward, one step back. But if the therapeutic relationship is strong and good, then there's room to be able to talk it through, and you can be there as their advocate, to talk with their team, if that's indicated.

  Alexis Reid  1:05:29

  I have, I have two kind of really good questions. One is, how, how common is it to also work with a nutritionist and the PCP as a mental health provider, kind of helping to support an individual and their families in this journey.  

  Dr. Aubrey Carpenter  1:05:47

  Yeah, I love doing it for someone that has moderate to severe illness. I would not work with somebody without a registered dietician on board. Also, they are just so knowledgeable. They are so incredible when it comes to the actual chemistry behind food like it is. I took an intro to nutrition class in college, and I was so humbled by how much math is involved and how much harder than it looks it is. So they are just so great at being able to calculate, you know, what the person needs in terms of the total daily energy, and thinking about if energy out is even safe right now. So, you know, we sometimes work with these athletes, who are incredible athletes, but the amount of energy that they would need to consume every single day and amount of protein, and you know, having this balanced plate is just far beyond what is ever realistic if they were to continue at the kind of sports level that they're used to. So dietitians can be really helpful in saying, you know, there's, there's just no way that you're going to be able to have that 10 to 12 meals a day, and you know, you want to pre qualify for the Olympics. So, like, you know, how do we think about how to maybe limit or scale back or add in an additional rest day, which can sometimes be like an exposure therapy hierarchy item, as to, like, actually rest day, when that might actually feel really hard. So I just think RD’s are incredible. They have often kind of a more extensive and depth of training that kind of a general nutritionist might not have I've worked with some incredible nutritionists who have done their own additional self study, but they don't have kind of automatically built in the same level of qualifications that a registered dietitian automatically has to get to be able to get their degree. So there can just be some variability. So that's another one where it's just important to kind of ask what their background and their training is they may be overly qualified to be a support to you, but I tend to look for RDs, especially again, if there's kind of moderate to severe illness, just to make sure that we're all on the same page and collaborating together. 

  Alexis Reid  1:07:56

  That's so great. And the other thing I was going to ask, and this is maybe a little plug for the educational side of what I do, because, you know, proactively, how do we support and teach just people, humans in general, all ages, right, not just young people. You know, I think it's so important to have an education and understanding of even some of this, because in any phase of life, anybody can experience what we're discussing here today, anybody can have some kind of unhealthy relationship with food, or perhaps there's some other mental health challenge that arises that results in more of an unhealthy relationship with food. But there's there's so much that's needed. There's so few educational opportunities that young people are getting in schools. You know, we have health and, you know, phys ed, and I always ask the students I work with, even the youngest ones, what are you learning? And oftentimes it's just so lost on them, because it comes from more of a deficit, or, like, a scare tactic mindset of like, oh, this is what you have to do otherwise this is going to happen. Versus like, I love the idea and the language of this is a relationship that we have. This is how we fuel our bodies. This is how we strengthen our bodies. This is how we learn to love and respect ourselves and each other. We're all different. We all have these different nuances and different experiences that might impact us. You know any from from you as the expert, Aubrey and Jerry, from your perspective too. What are your thoughts on how we better educate young people and and general the world on some of this outside of this podcast episode, of course.

  Dr. Aubrey Carpenter  1:09:35

  Such a great question. I know Jerry, I would love to hear from you too. I'll just say quickly, you know, I think pediatricians are just so incredible, and the ones in Vermont are just, they go above and beyond. I don't know how they do it, the PCPs too, like they are often just being thrown into this role of being psychiatrist, pediatrician, school, advocate, you know, all of these things. So I think they just, you know, have a pivotal role. Especially, because kids have to do these essentially required or strongly recommended annual well visits and then thick visits in between. There's also a fantastic registered dietitian named Jennifer Anderson whose Instagram handle is @kidseatincolor and she's incredible. She created, I forget the funder of the project, but she essentially had someone help her get all of these posters out into pediatricians offices. So I think we can all think about we've been exposed to that, have that very problematic BMI, you know, all of these, like, just really not helpful visuals that, again, were very well intentioned. I think sometimes it can be hard for pediatrician residents and training to reconcile this idea of the obesity epidemic with the eating disorder rate increase, and how do we kind of make sense of both of those things happening at the same time. So she just does such a great job in her Instagram and then the posters that she's had put out around the importance of balance on the plate, and, you know, not elevating desserts to be on this pedestal. Like, she, you know, recommends putting the desserts on the plate with everything else. Like, it's just another type of food. Like, this isn't something we have to earn. This isn't better than the broccoli or the french fries or chicken. Like, it's just all food. And they all, yeah, it's so great. So, yeah, I think there's just so much that, you know, pediatricians in particular can do. And then schools, I mean, they are just doing so much. I hesitate to say that they should be doing more, because every educator I know is kind of at the brink and loves what they do. But you know, they shouldn't have to be in this role of taking on one more thing. And yet they are the first line like they are sometimes the people that know our kids the best, beyond their immediate families. So they are just so great at giving opportunities to normalize conversations about food and this concept of Health at Every Size, which is, you know, kind of a branded term that a lot of dietitians and therapists will follow, just this idea that, like, we can have health at any size. It's not about the number on the scale. It's not about what's on your plate. It's not about, you know, what your growth curve is. There are all of these different pieces that go into it. So I do think, like community intervention is some of the best prevention efforts that we can take.

  Alexis Reid  1:12:15

  Yeah, and just going back to what you said about the educators, not that we want them to do anything more, but I think exactly what you said is so profound, right? Integration and the normalization of where we're at and how we treat our bodies, right? And I talk all the time about, you know, the fuel we put into our bodies, you know, when we lose attention, oftentimes, distraction can come from hunger, can come from exhaustion, can come from thirst, right? All these different really important things that allow for us to think and learn and contribute in different ways, in school and outside of school. So I think these conversations and normalizing it and integrating it is really the goal not to add one more thing to the plate, right? This plate we're speaking of hypothetically here today. But you know, really thinking about how we integrate that and being able to support having these open conversations, whether we recognize or see something or not.

  Before we kind of wrap up. I wonder too, Aubrey, you've mentioned so many aspects of the work that you do. I wonder if you can talk a little bit about just your practice right now and and the work that you do with with families and with individuals. And I'm so glad that you talked about your your patients who are male, who are kind of accepting and understanding themselves in the way that they are, and the work you're doing with them, because I think that that is such an underrepresented portion of individuals who are often struggling with eating challenges and disorders that doesn't really come to light. So I wonder if you can kind of just share a little bit with what would your elevator speech be, or feel free to share a little bit more than that about your work in practice right now. 

  Dr. Aubrey Carpenter  1:13:52

  Yeah, I'm happy to Yeah. So I founded this practice called It Takes A Village. And the full name is it takes a village parenting, wellness, consulting and psychotherapy, and it is now co owned by my wonderful business partner, Allie Legrand Hrindo, who's another licensed clinical psychologist. She also has some Boston roots. She did her research eight years at card back in the day, and so she and I are tag teaming, and it's just a really fun little practice. So we're based in a perinatal health collective building. So we have registered dietitian, lactation consultant. There's a yoga studio for prenatal, postnatal yoga, Kid yoga, regular adult yoga, which is so fun. Have a yoga studio right upstairs. We have a pelvic floor therapist who helped founded the entire building pelvic floor physical therapist. There is about to be an expansion of the other side, where we currently have massage therapy. We'll have even more massage therapy, acupuncture, a naturopath. So the focus is really on kind of more of the perinatal population, but I have essentially, kind of taken all of my years of training, working as a child and adolescent psychologist and doing family support within that context, and primarily serving parents right now. So I am seeing some adolescents and kids still, because they are just forever my first love. But what I really found through all of my years is, you know, parents are just the ones that are being asked to do the really hard stuff at the end of the day. They are the ones on the front lines. They are the ones who, you know, are doing all of the hard work behind the scenes. And it used to always just feel so difficult for me to recommend that a parent go seek their own individual therapy, or find a way to squeeze in family therapy on top of everything else that they were doing. And so many parents, I think, are happy to do whatever it takes, but trying to squeeze it all in has just, I think, felt really difficult for parents, and we now have insanely high cost of living. I think people's grocery bills are higher than they've ever been. There's a child care crisis. There's a housing market crisis. It is just unprecedented. So the US surgeons general kind of report that came out a couple of weeks ago, I don't know if everybody saw that, just that parenting stress is now considered to be a public health emergency. It was basically like my entire business model kind of put into a PSA. So it's so validating, but you know, just so sad to see that. You know, it's not just me seeing this like this is clearly a national crisis. So I really aim to provide support for parents who might be looking for acute help. So I really try to get parents in within one to two weeks, if I can. So I'm essentially taking my love of being a CL psychologist or an integrated care outpatient psychologist, and trying to kind of use it in the private practice setting. So I see parents for everything from, you know, I'm struggling with having just dropped my last baby off at college and being an empty nester to, you know, I'm postpartum and totally in it, and navigating anxiety and depression and not having the community I expected to have, and sleep deprivation and all of the things that comes up with that. I see parents of kids with eating disorders, parents of younger kids where, you know, oftentimes the experience of parenting has kind of brought up their own stuff that they thought they had coped with, or thought that they had kind of healed through and now they have to be in the trenches on the day to day. And they love their kids, but it's a very inconvenient time to work on yourself, who are also just running around all day long, just trying to kind of make ends meet. So they really try and kind of meet parents where they are and recognize that a lot of times parents don't have time for, you know, months and months of weekly therapy, or they just might not even know where to begin. So I really love supporting the parents that are like, I don't know what I need. I just need to brain dump out all of the things that are stressing me out, and then you tell me where I should go from here. So sometimes I might see parents just once or twice. Sometimes I might see them, you know, several times. Sometimes it turns into a longer term weekly patient. So it's pretty open ended. So we named it it takes a village, because the goal is to really help parents find their village and figure out what's missing. Is it that I need to scale back my hours at work? Is it that we actually need an additional source of income in the whole is it that we need to restructure our careers entirely. Is it that we need more babysitters so that we can just get room to breathe once in a while? So it's definitely more therapy than it is parent coaching. But there is kind of an element of really just essentially taking my own experience as a parent too, and just helping them know that, no, there's nothing wrong with feeling totally overwhelmed this unfortunate system, in reality, has made it such that they have no choice but to feel overwhelmed, and I hope to help them with that. And then my business partner Aliei Legrand Hrindo, specializes in women's health, so we have kind of a cool little tag team where she sees a lot of the perinatal and postpartum population, but also supports women who might be struggling with things like pelvic pain related to endometriosis, and has a background in trauma and OCD and anxiety work. So she tends to see more of the adult patients, and then I tend to see more of the parenting folks. So it's a really fun little little mix that we have going on.

  Alexis Reid  1:19:17

  Such incredible work, and there's so few options that do all the things that you just described, and it's all in one else. So I'm in awe. I'm thinking maybe I should move to Vermont. I love the work you're doing. If you need some executive function educational therapists there too, you know?  

  Gerald Reid  1:19:39

  And what a great person to provide this service. I mean, as the audience clearly can tell how smart and intellectual and competent you are. You're also just a wonderful person. And you know, as we know in therapy, that's both are important, equally important. And so you know people, you. Up in Vermont are lucky that you did relocate there and provide services there to the people and to give that space. We all, like you said, everybody gets overwhelmed for different reasons, in their own way. We all need that space to process and to work through things. And just happy to hear that you're still doing great work and you're up there supporting those Vermonters. 

  Dr. Aubrey Carpenter  1:20:20

  Absolutely, I do miss Boston, but it's it's nice to have a slightly bigger yard than I would have ever been able to make. 

  Gerald Reid  1:20:28

  Nature is good. Nothing like nature. Well, thank you so much, Aubrey. We're so happy. We'll have a lot of show notes on the website to share all the great resources that were indicated through this conversation, and maybe we'll have you back one day, and I'll talk more about this topic and other topics as well. Thank you so much. Aubrey.

  Alexis Reid  1:20:47

  Thank you. Yeah.

  Dr. Aubrey Carpenter  1:20:48

  Thank you both.

  Gerald Reid  

  Thanks for tuning in to the Reid Connect-ED podcast. Please remember that this is a podcast intended to educate and share ideas, but it is not a substitute for professional care that may be beneficial to you at different points of your life. If you are needed support, please contact your primary care physician, local hospital, educational institution, or support staff at your place of employment to seek out referrals for what may be most helpful for you. ideas shared here have been shaped by many years of training, incredible mentors research theory, evidence based practices and our work with individuals over the years, but it's not intended to represent the opinions of those we work with or who we are affiliated with. The reconnected podcast is hosted by siblings Alexis Reid and Dr. Gerald Reid. Original music is written and recorded by Gerald Reid (www.Jerapy.com) recording was done by Cyber Sound Studios. If you want to follow along on this journey with us the Reid Connect-ED podcast. we'll be releasing new episodes every two weeks each season so please subscribe for updates and notifications. Feel free to also follow us on Instagram @ReidConnectEdPodcast that's @ReidconnectEdPodcast and Twitter @ReidconnectEd. We are grateful for you joining us and we look forward to future episodes. In the meanwhile be curious, be open, and be well.

In this episode, we welcome our friend and colleague, Dr. Aubrey Carpenter, a licensed clinical psychologist who has spent over a decade working as a pediatric psychologist, educator and researcher in Child Mental Health and parenting support. Dr. Carpenter has extensive training and experience from the likes of Boston University, Massachusetts General Hospital, Boston Children’s Hospital, Hasbro Children's Hospital and Rhode Island Hospital. In this nuanced discussion, we dive deep into a comprehensive understanding of people’s relationship with food, the signs of disordered eating, self- and body-image, treatment for eating disorders, and resources for individuals and families affected by disordered eating. 

Be curious. Be Open. Be well.

The Reid Connect-Ed Podcast is hosted by Siblings, educational therapist, Alexis Reid, M.A. and licensed psychologist, Dr. Gerald Reid, produced by CyberSound Recording Studios, and original music is written and recorded by www.Jerapy.com

*Please note that different practitioners may have different opinions- this is our perspective and is intended to educate you on what may be possible.