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Compassion in a T-Shirt
Eating Disorder Recovery: Brain, Body, Soul | Warren Ward and Lexi Crouch
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- [00:01]
A
Hi, I'm Dr. Stan Steindl. Welcome to Compassion in a T shirt. Today's conversation brings together two powerful voices in the field of eating disorder recovery. One clinical, one lived, and both deeply compassionate. Dr. Warren Ward is Associate professor of Psychiatry at the University of Queensland and director of the Ramsey Clinic nufarm E Eating Disorders Program. A recipient of the Anz ead Distinguished Achievement Award, Warren has published widely and dedicated his career to helping people navigate the complex terrain of eating disorders. Lexi Crouch is a clinical nutritionist, recovery coach and passionate advocate who draws on her own 15 year journey with anorexia nervosa to walk alongside others with with empathy and wisdom. Together, Warren and Lexie have written Renourish, a groundbreaking new book that offers a three phase roadmap to recovery. Resetting the brain, refriending the body and renourishing the soul. And so I bring you Dr. Warren Ward and Lexi Crouch. Well, Warren Ward and Lexi Crouch, welcome to Compassion in a T shirt.
- [01:28]
B
Hello.
- [01:28]
C
Thanks for having us, Stan.
- [01:31]
B
Thanks, Dan. It's wonderful to be here.
- [01:33]
A
It's great to have you both. And just to show you again my copy of Renourish, your wonderful new book, a complete and compassionate guide to recovery from eating disorders. So, Warren, the book opens with the framing of eating disorders as a new epidemic. And so I guess I wondered from your perspective, your psychiatric perspective, what are the shifts in prevalence or how have we become more aware and what are the treatment challenges really that led you to this kind of framing at the start?
- [02:11]
B
Yeah, unfortunately I would frame eating disorders as an epidemic and a new epidemic. And when we understand the causes of eating disorders, especially the cultural contributors to them, it becomes easier to understand why we have an epidemic. But just in terms of the evidence that we have one, you know, back when I was a medical student, psychiatry registrar, we're talking 30 years ago, anorexia was seen as a rare condition, is described epidemiologically as rare. But. And then, you know, in the 90s and then early 2000s, Professor Philippa Hay, who's one of Australia's leading researchers with eating disorders, she actually did some community prevalence studies and she found, she repeated her community prevalence study in South Australia actually from 95 and then 10 years later to 2005, and she found that the prevalence of binging and purging in, in women in their 30s and 40s had doubled in that 10 years. Now, since 2005, a lot has happened and especially in terms of the media landscape, which is one of the contributors to eating disorders, there was a great study done by an anthropologist in the late 90s, Dr. Becker, she was a psychiatrist and anthropologist and she looked at the effects of prevalence of eating disorder behaviors in a small island in Fiji that didn't have television. And then she looked at that island after the arrival of television. And what she found was six months just after the arrival of television in teenage girls, body dissatisfaction, vomiting, to change, dieting, all those behaviors had jumped up by quite astronomical amounts. And that was just from watching shows like ER with George Clooney, Melrose Place and Xena, the Warrior Princess. So just by people looking at. Most American actresses have a certain body shape that say 1% of the population have that. That had a big effect on these teenage girls. Now that was all before these things were words. Smartphones, Snapchat, Facebook, Instagram, selfies, influences, and none of these things are words. And now we have a situation where young girls and boys, and I'd love to hear Lexi's take on this, are getting exposed to curated images of what an ideal body image looks like. And it's before their brains are capable of abstract critical thinking as well. So that's one of the reasons we have an epidemic. Because as we'll talk probably later in the podcast, the biggest cause of eating disorders is actually the brain not getting enough nutrition. It goes into an OCD like neuropsychiatric pattern. And so a lot of people are doing the experiment of depriving their body and brain of nutrition, and that's causing an epidemic. Also, some things we didn't have eight years ago, 24 hour gyms, we didn't have a demonization of carbohydrates until about 10 years ago. So all the. And these are not scientifically supported, these cultural trends. So we've got an epidemic caused by cultural factors. A lot of pressure on people to look a certain way and to focus on their diet, leading to a neuropsychiatric syndrome, a brain starvation syndrome that leads to binging, obsessive thinking about food and weight. And I like to liken it like to the epidemic of lung cancer in the 80s that was caused by a fact that cigarette smoking was culturally popular and encouraged. In the 50s and 60s, doctors used to smoke. My mother in the 70s was prescribed cigarettes for nerves. You know, that was a common thing. And so we had this epidemic 10 to 20 years later of lung cancer, which we have addressed through addressing the cultural factors. Even though it's a biological disease and brain starvation induced eating disorders are a biological condition more so than a psychological condition that have been shaped by this, this onslaught of all of us to look a certain way and to change the way we eat and monitor our calorie intake and our exercise. So there's a lot of. So that's why we're hoping with the book that we can help with prevention, awareness, early intervention, because as with any epidemic, you need to try and address the causes. Just one last bit of data before I hand over to you and Lexi. If you have two daughters and one decides to go on a diet, a restrictive diet, she's 18 times more likely to develop anorexia nervosa. And that has a 10% mortality rate within 10 years.
- [06:46]
A
Yeah. Yes. It's sort of a bit of a heartbreaking kind of story there, isn't it, in a way, you know, this kind of idea of all this human progress, supposedly, and yet with these ramifications, these trade offs, these really painful trade offs that lead to all sorts of suffering. And the thing I really appreciated about the book too was that you have a lot of research dotted throughout and you sort of go to that and speak to all of that and then you have these little, I'm not sure what they're called, but like little call out boxes where you tell stories and you talk about maybe specific clients that you've worked with or your own stories as well. And actually, I was going to just stick with you, Warren, just for a brief more moment if that's all right, because in that first chapter, I think you tell the story of Emily, perhaps, I think might have been the name. And you just said something at the end of that where it was kind of like talking about the beautiful qualities that society admires and, and that you were speaking to her mother, I think, about how some of these qualities are just, you know, that way and they are positive qualities and yet can get hooked, I guess, into these cultural, these societal kind of pressures or kind of lures that kind of dangle and speak a bit about that piece.
- [08:18]
B
Yes. So as I said, we know that the biggest risk factor for eating disorders is brain starvation. But there are, if you, if you get a group of 30 school students and you put them all on, put them all in the 40 hour famine, which I wouldn't recommend, there'll be two or three that are genetically predisposed to actually really get quite a buzz out of starvation and fasting. And we know from a large genetic study conducted by Cynthia Bullock in the States that the genes, the gene loci associated with anorexia nervosa in particular is also shown with gene loci that predict high Educational attainment, and that's separate and independent of intelligence. So there's something about the person who's driven, conscientious, organized. They're more likely to catch an eating disorder in this culture, unhealthy culture. And of course, that. That sort of. Those qualities we do admire, you know. And so my. Every week I get a new patient. And so often their parents are professors, doctors, lawyers, managers, successful people who are organized. And so we really support. So, yeah, that's another tragic aspect, I guess. And I sometimes see the. These patients as like the canary in the coal mine of our culture, which is a bit too focused on individual achievement and what I call left hemispheric activities of counting, measuring, performing, which is really encouraged in our culture rather than. As Lexi's beautiful lived experience stories. And her story of recovery explains, focusing on being more in your right hemisphere, focusing on things like presence, mindfulness, self, compassion, being connected to others. And so even though we're talking about eating disorders, this is probably true for anxiety disorders, which we've seen an epidemic of that as well in young people. Yeah.
- [10:10]
A
Lexi, you do really, very generously kind of bring your personal experience to. And sort of. Yeah, just sort of woven through, just to kind of bring it alive, I guess, that the sorts of. The guide itself and bring it alive with your experience. You describe it in one place there as sort of a horrendous and prolonged war between your body and yourself. And so that was sort of. I mean, even saying it now gives me little shivers. It's a very powerful sort of a notion. And. But so. So what was it like for you to. To bring some of that lived experience, as well as your own professional kind of point of view, but into the pages of Renourish and, you know. Yeah. Talk a little bit about what that was like for you.
- [10:59]
C
Yeah, it's. Yeah, it's a really different experience, but in the way that. I feel like people have asked this question before, particularly when you're in recovery, because they like to get a sense of where you're at, thinking, are you going back and are you reliving something that you've been through? But I've felt that since I've made recovery, and I mean really made recovery, it is a time where you put yourself in it. Like, you really go through it and you look at, I guess, the whole eating disorder and your patterns and your behavior from every different angle, and you feel it and you deal it. Deal with it, and you heal it. So it's kind of like when you come back And I found that when I was writing the book, it's kind of like how I would describe it. If someone who hasn't been through it before was if you're revisiting a relationship that you'd been in 12 years ago and you put it down to you might have been with this person. And at the time, as you move on, you think, oh, that's really interesting. I don't know why I would have been in that place or chose that partner or thought that that was fundamental to who I am today. But I remember being there, and I remember the things that I took away from it but not actually being in it, if that makes sense. So wrote it. It wasn't so much a healing experience, because I feel like I've really kind of put myself there. And that's why I work in the field that I do, because I'm able to be in a completely different place from the eating disorder than when I was in it. But it definitely just took me down to see how different I've become. Actually, I was listening to you both just chat then. And I was that personality type. I was so rigid. I was a high performer. I struggled really badly with OCD and anxiety, and there was just nothing that could break out of my anorexic pattern. And it was really difficult because people would see this as really admirable or really, you know, this discipline or this trait that you would have. And it was just such a battle for me just to have a bit of flexibility. If something fell out of my routine, it was severe punishment. It was. I just, you know, I barely did because it was so ingrained in me. But I just remember people looking at me going, oh, I wish I could be like that. And I remember just wishing I could have a sense of flexibility. I wish I could just go out there and just be in the moment. So it was quite interesting to, I guess, write. And because I have been on the recovery journey now for over 12 years, I of going, oh, wow, it really is a discovery of yourself. It was so naturally for me to write from the lived experience and talk about how I am today or the things that I've done to make me recover. But it was really, I guess, a trip down memory lane to feel how transformative you can be as a human. You know, you can be in a pattern, you can be in a place, but you can absolutely evolve and take form and grow until you're meant to be. So that's how I found the writing experience.
- [13:58]
A
Yes, it really is a message of hope. That's built into that, I guess, for the reader and so on, is the possibility. Is there that bit about rigidity versus flexibility? And it's interesting because I'd be curious to hear what you might think about this. But conscientiousness plus rigidity is versus what it might be. Conscientiousness plus flexibility. You know, whether that's a thing to ponder, I'm just thinking out loud. Really.
- [14:32]
C
Yeah, yeah. And it's really interesting, I think, you know, I touch on this or if I'm talking to someone or write about it. And the question I get asked a lot, it actually is one of the chapters I do remember is, doesn't make you a completely different person because there's so many traits. I think a lot of people who are going through an eating disorder, you know, you don't want to give up. You know, the things that fundamentally make you. You like. I do encompass a sense of discipline still. I have commitment, but it is not in a way that overrules my life. I'm able to look at myself in a way now of, I guess, my motive or how I would get my ethos per se is how is this going to make me feel? So instead of saying, this is what I do every day and I must commit to this, it's. I might go for a walk today, but I don't need to go too far. I'm a little bit tired. I might just go for a stroll, but, you know, it's still doing something that might be in a routine or if I need to miss a day, it's not going to beat you up. You're not going to be less of a person, but you're still committed to the things that are going to make you feel good and not bring you down in that element. I think so, yeah. It's very interesting, I think, from that, because you are often asked, are you a different person? And I guess there are. There are many traits that do make you up. And as you both spoke about that kind of genetic factor as well, it's in there. But when you go on that deep journey as well, you just get to look at yourself from different angles and reflect as well.
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A
Because that must be one of the great fears and barriers for change for people is to just. I can't even really imagine what that would be like to.
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B
To.
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A
To be different. And also, what if I, you know, have this wholesale change and I don't really know who I am anymore or I. Or I lose all my motivation and that sort of thing and so to be able to frame it in this, this sort of way that you describe it might be important reassurance that change is possible without necessarily losing all of who we, we are.
- [16:36]
C
Oh, exactly. And I feel like that's a recovery journey in itself. Stan, I can speak for myself and people that I do know personally. There is a huge fear, I guess in the word is, you know, quite black and white of losing control. And I think that is one of the biggest parts that I've seen. It was for me personally of not wanting to recovery, to recover. I guess, you know, it's a big shot because you're hearing from professionals who might not have had the experience themselves, but they can speak about how they feel life with flexibility in there. But because. Or you've had family members who want you to recover, but because they've not been through what you've been through. I guess they're just telling you from the other side. So it's a big risk, I guess, and you're not really much of a risk taker when you've got anorexia nervosa. Like you've got everything quite lined up and everything's quite calculated to throw yourself in and go, trust this. So that is one of the major things I think, that keep people in the illness for quite some time is that fear of loss and control because everything has been measured and I guess it impacts of your physical and your mental and life around you as well. So it is a big jump into the unknown. But if you are going through it, recovery is one of the best things that I've ever done in my life. So. Yes, yeah.
- [17:56]
A
Warren, you mentioned the concept of brain starvation a moment ago as well. And actually there was the fascinating study by Dr. Keys I think in like 1944 or whatever. You perhaps could, could speak to that. But, but yeah, what are some of the, the neurological effects really of, of malnutrition or starvation? And how does really understanding that help with recovery and, and, and even just reducing some of the psychological aspects? Shame and, and so on?
- [18:27]
B
Yeah, no, that's, that is a central aspect of the book and one of the reasons the publisher really wanted to get this information out there that brain starvation changes the way we think. And as Lexi is so eloquently, I think, explained eating disorders, we think of them as about the content of thought about weight, shape. But actually a lot of it's about how you're thinking, not just the content. And the thinking becomes very obsessive and controlled and repetitive and self reinforcing. And there are two, there are a couple of different pathways to being so obsessive that you're willing to harm or deprive yourself to follow all the rules you have. We all have rules in life and rituals. One is to start your brain that will give you get your hardware such that it's really in a sort of rigid, ritualized way. The other is trauma. You know, early trauma can make us want to have more control and some of us just have personalities or cultural circumstances where we're encouraged to be following rules and being in control. But to answer your question, yeah. A landmark study was done in the forties by Professor Ancel Keys, K E Y s called the Minnesota Semi Starvation Study. And in that study he got 36 men who were mentally and physically healthy. They were screened for that. And then he put them all on a diet to, on rations to lose 25% of their body weight. And then he observed them for six months. Then he renourished them for the final three months. And what he found was apart from all the physical and physiological, physiological changes, those men, 100% of them had profound changes in their, their type of thinking, emotions and behavior. They all became obsessed with food, thinking about it all the time, swapping recipes. But they also developed what we call the three Rs or what we in the book called the three Rs rituals, rigidity and rules. They became a big part of their content of their thinking not just around food, but around everything. We've added a few other Rs too. Regimentation, further restriction, but. And they also all became depressed. And three of them were admitted to a psychiatric unit with suicidal thoughts just from the biological effects of starvation. One chop three of his fingers off in a self harm attempt. And they all developed what we call proofreader thinking where they lost the ability to look at the big picture and just got really focused on detail. When they were handed their rations, they'd take up to two hours to complete. Want to eat it in complete silence. After rearranging the food in certain shapes and arrangements on the plate, they got into hoarding food. Later binging food, also purging. And during the refeeding phase they became very, their obsessive lens, if you like, became focused on body changes. But when they were renourished, all of them, their brain, their thinking returned to normal. But three did change their occupation to chef. So it had sort of some effect if you like. And these men I, I should have mentioned were very conscientious men anyway, because they were conscientious. Objects, objectors to military service. And in those days, if you're conscientious objector, you would go to prison. But you had a third exper. Option, which was to go in a medical experiment. And that's what these men did. Anyone who's worked in the eating disorder sector, which is a bit of a subspecialty, still would have seen this happen hundreds and hundreds of times. You know, Lexi and I have seen this happen hundreds and hundreds of times where normal, conscientious person goes on a diet after a relationship breakup, decides to start counting their steps or get a bit healthy, cut out carbs. Next thing they say, they cross a red line where they're no longer controlling the thinking, the thinking's controlling them. And they can't actually eat anything because they overthink everything. And when we renourish their brain, I'd say 40% of people we treat just by renourishing their brain, their anorexia disappears. And so you have to coach them to do the thing they're most terrified of. And it's. It's often a long process, but explaining that to the patient and their family, which I always do in the first session, they start nodding and go, oh, my God. And I said, can you remember what you were like before you went nuts? And they don't mind me using that language. So they go, yeah, I was flexible. I was carefree. I didn't worry that much about food. And do you remember, you know, when. When your brain sort of crossed the line and it started controlling you? And they do, and they want to get back to freedom, but they're. They're terrified as well. It's. It's. But that educate. And whenever I teach doctors, psychologists, emergency department doctors, and Lexi and I have done a lot of training together, training clinicians. We always share that study first. And people start to go, oh, so it's not their fault. They're not just vain people who want to be thin. Their brains have been triggered into this syndrome, and we can reverse it.
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A
Yeah. Does that mean that it starts with food and. And calories and re.
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B
Eating?
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A
Is that where renourish kind of starts?
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B
Or.
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A
Or is it starting psychologically sort of in preparation for that? What, what are your sequencing there?
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B
Yeah, the sequencing there is. I say, let's. We gotta fix the hardware before we fix the software. And so biologically, we need to renourish your brain to at least talk about where it's thinking reasonably flexibly. And also when your brain's bitten better nourished, you're Able to take on viewpoints of other people and consider them. But when you're not, you're so trapped in your own thinking. And then once we do that, you need this. The psychotherapy and the psychotherapy and all the evidence based psychotherapy such as CBTE do focus on regular nutrition because that's important for the hardware, but also on finding ways to break, to stop checking things. Because every time you check things like your weight, your thigh gap, your calorie intake, your steps, it actually the brain sees it important. You can get in this OCD loop. But psychotherapy is about dealing with. The goal of psychotherapy is to deal with thoughts and emotions in ways other than by trying to manage your weight or your food intake. So it's creating the repertoire because we all do it actually we all use food and exercise and rules as a way of deal managing effect. But it's to do it in a way that doesn't harm ourselves. And so we have a repertoire of other things affect regulation techniques. We've actually developed the Brain Renourishment Scale, which is scale all the patients in our inpatient unit, new thumb fill out. And it's just a simple, like that scale from 0 to 10 where they rate themselves every week as their brain's being renourished on how flexible their thinking is, their ability to take on other people's viewpoints, their mood. And we found that every single patient has come through our renourishment program has improved in that, on that scale that's very helpful and that's probably a way we'd suggest programs, current programs should change because too many programs are focused on getting to someone to a normal bmi. We don't really like that term. And then we discharge them. But we say let's get their brain to flexible thinking so they're ready for psychotherapy. And let's use a scale like the Brain Renourishment Scale to help them see that their brain is getting better. And so that's been a big breakthrough in our treatment because in the old days after two weeks a person would say you're feeding me too much food, I'm terrified I'm going to put on weight, I think I need to discharge myself. And that. To which I'd say, how's your brain on the brain renourishment Scale? And they go, oh, it's about a 4 out of 10. What was it when you arrived? Zero. Would you like it to get better? Yeah, well, I'll stay right.
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A
There's a sort of a. You're dealing with motivational components there, in a way. And the difficulty is that starvation compromises all of that. It's much harder to kind of come to a, a sense of where you want to head and what the motivations are. And in a way, you're kind of in this very back and forth threat system where starvation itself is threatening, obviously in that very human sort of living sense. But on the other hand, all of these other, this other stuff is activating threat system as well, and we're not able to kind of think our way through it. The other part of that, I think Lexi too, is in chapter seven there you, you talk about certain myths, I guess, myths that weight equals health or, or, you know, those sorts of things and, and, and other myths. And what did you notice in your own experience in terms of, you know, some of those myths and, and so on. But, and, and, and what would you say to someone now, you know, that's still caught in some of those mindsets?
- [26:52]
C
Yeah, it's, I definitely say, Stan, I look at health in a totally different way. I was actually nodding along to what you guys are just talking about just then. And there's so many times that I'm just sitting there and could completely relate, like I definitely was that person in the study. And just to shed a little bit of light on that, I think, because you, you're always a person underneath. And I think that is a stigma with eating disorders. You know, you can get labeled as something, but just like everybody else, you're, you're experiencing the world as you see it. And I would notice when I would starve myself and my brain, because you feel it change, you just wake up one day. And my wording to myself would be, lexi, you've gone too far again. And that's exactly, I mean, that is my personality type that works great in entrepreneurship these days because it's pushing the boundaries there, which I have come to light to myself. But it was just the way that I think I would look at that because obviously there's the psychology around eating disorders as well. But you do encompass this sense of commitment. So, you know, once you've kind of said that you're going to do something to the eating disorder, it kind of continues to go down that pathway. And that's why it can be so hard to break out of it and you just develop this rigidity. So I was nodding along to that and brings me to how I just see health so differently now. And it was, I would say it definitely was how I was growing up. And I saw the world. And it's very different health as we see it today. You know, this was a very. Back in the 90s where it was very. Quite linear. It was very black and white where we used to talk about just a lot of data to measure weight. Actually, you know, it would be calories or measurements and, you know, were you thin? Have you put on weight? And, you know, even grandparents, you know, not just speaking about my grandparents. I mean, in general, you know, every time you would see them, they would go, oh, oh, you've put on weight or you've lost weight. Like, it was this definition of health and happiness. And I guess when we were writing that chapter and Warren, I kind of speak for you in this one, is just how we look at health differently today. I know for me, it's something that I would want to tell people. I don't look at it to do with my weight whatsoever. Honestly. I can't remember last time I even have been on a set of scales. Like, that's not a big indicator at all for health at all. I think it's measured in how are you feeling energetically, how much are you sleeping, what is your mood like, how are your reactions, how's your emotionality. And it's this whole big picture of this broad meaning of what is actually health rather than a whole how much you're actually weighing all your physical kind of appearance, I guess, in that one. So I guess when we're writing that, it's just looking at, you know, there is so much more to you than just losing weight or what that might mean. And I think in my experience as well, I, yeah, I had a very big journey with an eating disorder. So, you know, it was over 15 years. And it's not so straightforward, the path. You know, it's not, you know, you don't develop anorexia and you're on this downward spiral. I was somebody who was in the hospital systems for years, so there's a lot of refeeding. And, you know, your weight might go up and then you. You might relapse, and then it goes down. And you see this whole. Messy is the word, I think, experience of the illness. Whereas still, I think society might portray it as this. You know, you only see this one kind of side, but can be very messy, the eating disorders in general. So I think I got to learn a lot about health because at some of my higher weights, where I was completely starved, and this had, I guess, you know, it had. It had to do with some medications that we're trying to see if that was going to help with my brain to think, you know, less rigidly or something. But it ended up having an effect on my body where, you know, I was probably eating next to nothing and you couldn't actually physically tell that I was in a severe starvation state at the time. And then, you know, you'd get different. Different ways of being treated or I think professionally even know doctors were kind of learning about the illness itself, not realizing that you were in a not great position. And then there were also times where I'd been at extremely malnourished weights, you know, unrecognizable, like, for the person that I was. And I felt like I was doing much better then at some of the higher weights. So it gave me this really big perspective about health and how little it has to do with how much you actually weigh. It also gave me the experience of a lifetime to learn not to be judgmental, because you never know how somebody is feeling based on their looks as well. So I think that's kind of where we were going with that direction, that health is just so not straightforward. It's not based on just the weight in our bodies, but a whole picture as well.
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A
But isn't it amazing how the myth persists? I feel it still seems out there, you know, in a way, and it's not uncommon for a client of mine to arrive and. And have very difficult feelings about an interaction with a gp, for example, who has still said, you know, you. You need to lose weight. And, and maybe the person I'm talking to hears that through a bit of a lens of their own, maybe. But also, it just seems like the. The myths persist and, and, and despite, you know, all that has been done, for example, the notion of health at every size. Could you just explain to us what that sort of approach is about?
- [32:37]
C
I think it generally is looking at just how everybody is made up. And I think, like, the GP example is a great one because it can be quite linear to. I guess Warren and I talk about this. BMI is not our favorite, but it is a measure that they do have in the system to, I guess, have something to go by. But when we look at people's health, health and why they might sit at, you know, maybe a higher disposition and be healthier. We're not looking at the bigger picture. Like, we've still got hormones to factor in. We've got what is happening with that person's stress levels, like, what is, you know, the cortisol that's running through that person's body. And there's just whole different factors to look at. And bodies are completely different. So we know that there's genetics that make up how we look. We know that obviously there's medical conditions, there are many different factors. So when we look at health at every size, you've really got to break it down to look at the individual. And I think that's why it can be really just disappointing or people get really, you know, traumatized, I think would be the word. And I do work with some of these people in my space because they don't want to go back because sometimes it can be just so I guess put in a linear scale of you need to lose weight to be healthy when we're not looking at the big picture picture or taking in individual circumstances. So that would definitely be the health at every size in that element.
- [33:59]
A
Yeah, sort of. They're traumatized and shamed and it just. Yes, it's a remarkable thing. Warren, I've noticed lots of Rs in your book. If I've picked up the right thing. Renourish, of course, and you mentioned the model with a few hours before. But the book itself is structured in three phases. Resetting the brain, refriending the body, renourishing the soul. How did, I guess that model evolve, perhaps in your clinical work? And why do you sort of see that as the effective framework for recovery?
- [34:36]
B
Yeah, that's really been forged with, I guess, trial and error, working with a lot of patients over many years. But I think people with eating disorders generally do like structure, and so to give them some structure is important. But I think the thing that's. We've talked about brain renourishment being central and primary, and it's also the scales fall from people's eyes when you explain this. And still 95% of doctors, psychiatrists, psychologists, other clinicians do not know about brain starvation. They think a bit of counseling might be what someone's needed. So I think that's important to put that at the center. The second part of the book, which is about refriending the body, it's about really renourishing the body. And it. It follows on from what Lexi was saying, that we think we can measure someone's physical renourishment through their bmi. That that is decidedly false. And so we look at a more sophisticated approach to looking at. To help someone look at their own level of nourishment. And I always say in my training, there are nine better indicators than weight of your current nutritional state. So this is trying to improve nutritional literacy. And we talk about the idea that certain organs will go into low power mode if you're not getting enough nutrition. One example would be the ovaries. So we know that 60% of women presenting to infertility clinics, because infertility is a big issue in our society who have menstrual irregularities. It's because their weight's too low. But there are women who are BMI, 18, 19 or 20 whose friends and family and GP will all be saying, you look great. What's your secret? You know, you look so healthy, but they're actually undernourished because we know that you need 25% of body fat for 50% of women to menstruate. So that's just one little example of how we don't really have a good understanding of what healthy is in terms of organs running. You know, we, we're meant to be. And also the large studies show that, the large meta analyses show that a BI of 25 to 30 is actually associated with a longer lifespan. But you're at risk there of your GP saying you need to lose weight. So there's a lot of information about the body. And also a lot of our patients work in health sciences. They're doctors, nurses, really common psychologists, a lot of our patients. And they're interested in their body and how it works. They're intelligent people. And so to explain to them the reason you're getting hypoglycemia and low glucose is because your body doesn't have enough stored glucose in your liver. And again, to have enough glucose in your liver and your muscles, you need to have a bit of extra nutrition on board between meals. And so this is very countercultural, all these ideas. The last section is really important and Lexi has helped me so much with this, you know, over the years that we've been working together. And that's renourishing the soul because people who get maybe not as slow to recover with these, with the quick fix of brain renourishment, it's often because they're stuck in the culture that is a patriarchal, consumerist, capitalist culture that tells us all that we, we're not good enough and we need to do something to look better or to feel better. And so reframing that is having a better kind of relationship with yourself, which I know is the theme of your whole podcast, is actually so important. And a lot of work I do is weekly long standing work with people's long standing eating disorders. And there's a good evidence base to support this, not focusing at all on numbers or what they're eating or how much exercise they're doing but the person inside and whether they can love and be kind to themselves and gentle with themselves rather than harsh. So we do a lot of schema therapy approaches are helpful in this third section of looking at that harsh inner critic or the inner dictator. And again, I'd love to Alexi's thoughts about the inner dictator. I'm sure she had one from hearing their stories. But I think a lot of us health professionals can relate to this too. This is a broader cultural issue for our general mental health.
- [38:30]
A
Yeah. So there's the sort of the resetting the brain, the sort of literally nourishing through nutrition. It's sort of the refriending your body and getting an understanding of the body and how it's working and perhaps a sort of a return to kind of vitality across the multi dimensional aspects of it. And then the renourishing the soul bit. I was actually going to go to you Lexi on this too and sort of see because, well, the third section of the book, it talks about connection, emotions and self compassion which is certainly particularly interesting for me. And you do describe in fact in there your inner bully I think was perhaps the phrasing and sort of including as you were into your recovery I think is how you put that. But yeah, so tell us a bit more about renourishing, nourishing the soul and you know, dealing with that, that kind of inner bully or critic and perhaps moving towards self compassion.
- [39:32]
C
Yeah, and I just think it's really interesting like I love listening, listening to Warren talk as well. I feel like we just bring our two different combinations in together to I guess try our best to help people through the different avenues. But it's so fascinating because I remember one of the many attempts of recovery. It's not a put in your calendar kind of day and remember is a journey. And I remember there was a lot of frustration because I was working so hard on the first two elements, so renourishing the mind and renourishing the body. And I was so depressed, I was morbidly depressed in recovery going I don't really understand and you know, I like to consider myself a smart girl as well. So once I'd really connected to the fact that I was going to do recovery, keeping in mind I still had the very rigid thinking I was going to do it well and I was going to excel because this is what I've always done and used to be so frustrating because I was doing those two and I guess that was a reason why I would continue to relapse as well, because you weren't really experiencing anything from it. You were doing the things that you were trying so hard to run away with with the eating disorder. So it didn't make a lot of sense. I guess also when you had health professionals telling you to just eat your food and turn up to your psychological appointments as well, you know, it's. You kind of know that. And again, I think Warren even articulated that really well. A lot of us have studied the body, A lot of us have studied the mind. And you know, to have an eating disorder, you're constantly observing. You know, you're making decisions of am I going to eat this apple or am I going to do this? So, you know, you're very switched on. You know what's going. So it can be very frustrating in recovery where it's not giving you the life that you thought it was going to go down into. Experiences, I guess, Joy. But the interesting thing is, I think with recovery is because you're still in that rigid thinking and black and white, you don't really want to step too far out of your comfort zone and you've kind of seen the world in a very, I guess, conventional way. So I know for me, that's my personal experience. And I grew up in a medical household as well. So again, very frustrating when I wasn't getting anywhere with recovery. And that led me, I think, when I was ready to start seeing things a little bit differently. And for me, I consider myself lucky now, Stan, that I did have situations where I was just so sick and tired of feeling just so sick and tired and miserable with the eating disorder that I was forced to explore different avenues. And also at this point, I think it become a little bit, I don't want to say the word as a joke, but turning up to different appointments and turning different things, I was very, I guess, very sarcastic and very wanted to prove everybody wrong that I couldn't recover, that I would start to even, I guess, let little creeks in of experiences, experiences that might start to help me down the track. So that was when I stepped into a little bit of yoga or starting to listen to people a little bit more that were, I guess, not conventional or the way that I'd always seen the medical system. And for me, it was really, I guess I use yoga a bit as just my first time that I did try something that was what I thought at the time left field to start to experience something that I didn't have control over. So I remember getting into yoga and I did not like it at first because you're doing everything that the eating disorder prevented you from wanting to do. Starting to feel things, starting to slow down, starting to, yeah, the voice that is underneath, I guess. And it was these little steps that it was very confronting at first when I started to get into that so much that I'd run away and think that it was all rubbish because I wasn't getting any instant gratification like when the eating disorder first gave me. So it was so easy to want to, want to go back to that and, and start to see some results. So it took a big part the longer, the short of the answer here to really get into I guess the different ways of what the groundwork of the self recovery is. So really starting to get to know who is the person underneath. And I wasn't somebody, I didn't really know what the word soul was. I probably would have been a bit embarrassed to use that in a sentence as well. You know, to think, oh, where's my discipline gone? Like I'm very, you know, I wouldn't say the word was ego but you know, eating disorder, very controlled. You wouldn't want to think that there was anything else outside of your own thoughts and control that could possibly have an answer to make you feel good. So I went down again a little bit more of that unconventional track in combination with my medical as well and started to get into yoga. Starting to get into a little bit of more self compassion and showing ways to myself that I could show up for myself rather than just the eating disorder. So I knew that I didn't have a problem with commitment. You know, I used to have to show up to anorexia every day. And I say that for anyone with an eating disorder it's not about, you know, that you can't show up or be there for yourself. I know you can do that because anorexia has made you turn up. You don't choose to have an eating disorder. You don't just go, I'm going to do this today and not do it the next day. You know, it's something that's with you. So you've got that sense that you can start to show up for yourself. And this is a whole new way of learning a different, I guess pattern or way of living. So was a very slow journey recovery for me, which I'm really glad because it really got, got me to stick with it because if it was going to be fast, if it was going to give instant shiny results, it would have gone quicker than it came. Stand so this is lifelong learning for me. Like 12 years down the track. I am still a daily yoga practitioner. And that looks very different. Even when I first started, you know, I was very in that eating disorder mindset where it was, I will practice this many sun salutations through day, through the day, and I will turn up at this time. And slowly by slowly, things just started to melt away. And I guess this is somewhat, I guess, the whole magic of yoga that we can't really talk about because it does operate on a different frequency and it steps away from, I guess, the whole eating disorder talk where it likes to have that control, because that's where I really started to, I guess, pinpoint that I was in recovery. It wasn't so much that it was, you know, something that I could measure. It was more a year down the track. I'd just be caught off one, One day off guard and go, oh, my gosh, no, I did stop weighing myself. And that hasn't happened for months now. So it was this gradual way and it was kind of lifting, I guess, what I say, this heaviness. So that inner bully and the voice, it wasn't that it disappeared overnight. It was more that I was starting to replace different habits that were building me up. Well, I could still beat myself up as well. Like, I'm a big believer of adding things in rather than taking them away because if they're not meant to be there, they'll fall away because you'll get bored of them. And that's what the eating disorder and recovery happened for me. Like, all of a sudden there were these little things that, yeah, they felt unique, they felt strange, they felt weird. But I kept showing up because I had no other choice. When you're at rock bottom, that's a great place to start because what else are you going to do then try something? And it wasn't until I started to build more on this inner world that just these kind of habits or, you know, the ability to just relax, it just started to soften that voice per se. And, you know, I really had to go through the ringers then. Really, it's not, you know, I wish recovery was a graceful process. I wish it was that I went to yoga. I wish it was that easy. But it brought up whole different patterns that, you know, I really just had to go through it like it was some dark times. And, you know, did I have to let my eating, eating go out of control?
- [47:39]
A
Yes.
- [47:39]
C
But did I have to find a journey back to myself to trust myself? Yes. And it was just Believing that, you know, something in there, wanted something more for myself. But that was I guess comes back to what we're talking at the beginning it was that fear of losing control. But if you can sit through that, be surrounded by the good people, learn some different habits that are going to be enhancing. Although they might feel strange at first, you're going to start to make a little bit of groundwork. So slow process but essentially started to soften and it's something that I live and breathe today and in my work, Warren's work is just if you could touch on that and share that there is a possibility for others, you'd want to help them with just a different way of seeing life, I guess. So long answer.
- [48:23]
B
But that's good answer.
- [48:25]
A
Very, very good answer. And also we talk on this channel and podcast a lot about fears, blocks and resistances to self compassion. You know that idea that it sounds great in a way, you know, self compassion, sure. But it up comes lots of different thoughts and feelings about it which can make it really difficult. It can, it can be a scary thought. We can sort of feel, you know, blocked like how do I even do this thing? You know, we can resist it because you know, of, of how we've always done things and so on. And you just gave a really great example of. In some ways it's a bit like just graduate gradual exposure to it, isn't it? You know, like it is a scary thought to change and be more self compassionate but if we can take little steps up the hierarchy and gradually expose ourselves to kind of being kinder to ourselves then then gradually it feels more comfortable and we can get there.
- [49:23]
C
Yeah, definitely Stan and I feel, you know, you start to build up this self esteem as well when you get there. And I know for me I wasn't really expecting exposed to too many people as well. I just thought that I was this ineffective eating disorder girl who had spent her life in and out of hospital. And it wasn't until I was getting out there slowly and you know, socializing was something like that was not high on my to do list. Like you know, I'm an introvert to these days actually, you know, I've got my beautiful circle and we touch on that, you know in the book as well about quality and you know, the people that you meet along the way. But also what I felt with just self compassion and everything was when I got out there to realize that everybody's on a journey, everybody that you talk to is going through something and they've got their own inner critic that, you know, that goes on for them, it might be their own shame spiral from different, different impacts of their life or things that have happened. And you know, an eating disorder is just one that you've just chosen to go down that pathway to I guess numb it a little bit. But it doesn't make you any less effective. You can still give yourself self compassion and also realize that we're all on this journey together. So I think that was a big one as well.
- [50:35]
A
Warren. I mean Lexi is very inspiring, isn't she? And just to listen to the wisdom that weaves through all that. I mean you've collaborated with a lot of people and you've led teams and so on. I mean, what was it like for you coming to the book as, as a psychiatrist and coming from that professional thinking kind of medical sort of idea? I mean you're very experienced as well in your life and so on I suppose. But working with someone where the lived experience and the professional education was sort of being brought to the table. How was that collaboration for you?
- [51:13]
B
Yeah, I think sometimes there's a bit of lip service given to the recovery model or lived experience. But I've been fortunate to be, to see that really active transforming healthcare services. But that journey for me began like after I'd finished medicine, then psychiatry, I actually did a business management course which was really helpful. And so when I inherited the eating disorder program at the rural Brisbane as a young psychiatrist youngish, the nurses were demoralized. The patients had been there for many months. There didn't seem to be any clear, clear process for treatment and the patients kept coming back in. And so I think there was a negative, hopeless feeling amongst the staff about the patients. There were not any evidence based treatments back then either. And so I thought, well, if this was a business, what we would do, we'd get a past customer to come back and talk to us about how we can do better. And so we, I started a planning day and as well as giving a chance for all the staff to talk about how they think the program should go forward, I asked a past patient who'd been through the program, had fully recovered, to come and talk to us for an hour about what it was like when they were sick, what we did when they came into hospital that helped them, what we did that made it worse and what life is like now. And hearing that and I also heard from a parent and we did that every year actually a parent spoke for an hour about their experience with having an E and just the whole attitude of the nursing Staff and other staff changed because they saw, oh, this is what we do this to get these people better. But of course, the people get better. If you work in an inpatient setting, you don't see them, you know, you only see the ones that keep coming back. And the other important thing was these patients also said the things that really helped them most of all were a nurse saying a kind word in their ear like, you know, you've got this, or getting to know them as a person. The sort of thing that Lexi talked about. And that was transformational. So we can use all our technologies to treat, but there's also vitamin K that's needed kindness in. In treatment settings. And which is your whole podcast is about which I really appreciate. But then later, eating sort of. Queensland started to train speakers, people who recovered, including Lexi. And I met Lexi because she came to a. I was asked to train psychiatry registrars, and I feel I can give them the knowledge about brain starvation and the skills about CBT. But Lexi actually spoke for about 45 minutes and she talked about what it was like as a little girl to be asked to your friend of Jenny Craig to be fat shamed. And then in a conscientious way, a logical way to. To develop an eating disorder, if you like. And then she mentioned in the talk that she was sitting the gamsat, you know, to become a doctor, possibly that. That week. And I just walked away from that thinking, all those. All those registrars, it's like watching a Netflix film. They all had not only knowledge and skills, but a motivation to help people who unfortunately catch eating disorders to go and be the best people they can be. So it changed attitudes. And we know when we're working with other staff, we like people with good knowledge and good skills, but there's nothing like the attitude of wanting to learn and having compassion for patients. And then later, I and Lexi are both involved with Wandi Nerida, Australia's first residential program for eating disorders. And in that program, at least a third of the staff have recovered from an eating disorder. The charged nurse had bulimia for 15 years. She thought it was untreatable, but now she's recovered. And that just naturally, I think, helps the staff to see patients as just humans like us who are afflicted with this thing. And we're coaching them to try and find their own way to be their best self. So for me, lived experience has been a critical part of. And now when I see patients, I say, well, people who've recovered tell me this. People who struggled recovery this is the way they were thinking about it. I use bibliotherapy a lot. I prescribe for nearly all our inpatients and outpatients a book by Carolyn Coston called 8 Keys to Recovery, which describes her journey of recovery. And we're hoping our book will add to that library of tools that people can use to. On that as. As Lexi said that the difficult individual journey of recovery rather. And. And we as treaters, I think are resources for them along that individualized journey.
- [55:36]
A
Yes, I was going to say that I, I have stumbled across this really great book that you could start to give. Give people as well. But I, I'll let you both go in a moment. But, but Lexi. Yeah. If someone perhaps is sort of thinking about this or maybe is early in their recovery or is kind of, you know, kind of opening up to thinking about what to do, I suppose, like, what would be just one message from you? What would you most want them to perhaps carry with them?
- [56:16]
C
Oh, that you can do it. And I know that that is a very short and you know, could be misinterpreted in many ways that one. But it's what I mean to say from that is eating disorders, you're not ineffective if you have an eating disorder, you have this massive drive and massive gift to give back to the world around you. And I don't just say that because of me. I've met other people who have gone on to recover and they are living these full, abundant lives. And I can say we're all very different, you know, but I feel like there's always been this burning spark that is so passionate to go out there and live your life fully. And you know, I believe in that yin and yang balance too, Stan, in the sense of if you've gone one direction to completely shut down because, you know, you might not be there with your self esteem and you might not think that you can do it. And you know, you've been told by society to stay small, not just physically but also mentally, that when you go through the recovery journey, you know, you come out and you are the yang side. You're this really cool like, you know, I enjoy, I can now and say I enjoy my big intense personality. You know, it's. It's not for everyone, but it is for me. And when I say that, just believe that you can do it. It is just, you know, you've got it in you. And there are so many people that are supportive of you now to know that it's not as straightforward as it used to be like, people want to empower you, and it's just taking the plunge. You know, it. It's terrifying. Change is terrifying. I know what it's like to be stuck in that mindset. But, you know, you've got to risk it to feel the results. And it's what I say. Even when I teaching yoga, if I had any of my students listening to this one, I always say, find some comfort in discomfort. So. Meaning that recovery is going to be uncomfortable when you start to build that inner world. You're going to find some comfort in who you truly are and get out on the other side. So I believe in you. That's probably what I would want the most to say.
- [58:26]
A
Yeah. Well, Lexi Crouch and Warren Ward. It's a great book. It is a book of hope, really. And that sense that you can do it, you know, that's really the key message. I'll put links to all of that in the description. And Lexi has a really great Instagram page as well that you might want to follow. She puts up lots of really great content there. But thank you both for coming and speaking with me on compassion in a T shirt.
- [58:56]
B
Thanks so much, Stan. It's been great talking.
- [58:59]
C
Such a joy. Thank you.