Latest / Radically Genuine / 119. Treating Eating Disorders in a broken system w/ Dr. Anita Federici

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119. Treating Eating Disorders in a broken system w/ Dr. Anita Federici · Radically Genuine

• Welcome to the radically genuine podcast. I am Dr. Roger McFillin. As many are aware, I am an outspoken critic of the psychiatric industrial complex and the harm that is created in the disguise of standard mental health care. This extends way beyond psychiatric labels and drugs and also include psychotherapies. This, this does not suggest that good therapy doesn't exist or it's not available. In fact, do believe good treatment can be life-saving. And I am proud to call myself a clinical psychologist, one that does incorporate scientific findings with compassionate, ethical, and comprehensive understandings of emotional and behavioral struggles that are driven by contextual understandings of why people might struggle, including their histories and modern neuroscience and considering things from a biopsychosocial, spiritual, environmental perspective. In my field, I remain appalled by how two conditions are generally treated. And these conditions are most widely experienced by females and the labels attached to females generally. The two conditions, one borderline personality disorder, and then the second, the range of eating disorders that exist, most specifically anorexia. Nervosa bulimia nervosa. These are two areas that I have devoted a lot of my career to understanding and treating. I have some strong opinions in this area, but have generally resisted even discussing them to a great extent on the radically genuine podcast. There's reasons for that, but I think it was time. It was time to bring in a guest with established expertise in these areas and to discuss what works with whom under what conditions Sean (02:01.365) to be critical of our field, but also to acknowledge, you know, how people are helped and what we are learning through our clinical and research experiences. To do that, I'm proud to bring on Dr. Anita Federici, who's also a clinical psychologist, and she is the owner of the Center for Psychology and Emotion Regulation. She serves as an adjunct faculty member at York University and is a distinguished fellow of the Academy for Eating Disorders. Anita has... provided more than 375 lectures, workshops, and invited talks on eating disorders. Her program, much like ours, has a comprehensive dialectical behavior program treatment, but she's also kind of extended it to some of the newer treatments that exist, including radically open DBT. These treatments are very effective and have been proven over decades, but they're often misrepresented in media, certainly in other countries too. You know, we're here in the United States, and Nita is in Canada, and I can't wait to kind of have some discussion on some of the differences in the healthcare system. But I just, from being connected to social media, you see how a lot of these therapies are really, you know, misrepresented publicly. Sean (03:29.181) international conferences, she's published in peer reviewed journals, and invited book chapters. Dr. Federici, I want to welcome you to the radically genuine podcast. Anita Federici (she/her) (03:41.188) Thank you. I loved your introduction about who you are. I think it's a great fit for me too. And so thanks for inviting me. It's great to be here. Sean (03:51.849) Well, welcome. We do appreciate it. Your expertise is well known. I've listened to you on some other podcasts and you know, it's been difficult for me to find someone who I think I can really trust to have this conversation and your background demonstrates it. I do have some questions about what brought you to this place in your career. I think people become psychologists and therapists for different reasons, but when someone chooses to focus expertise on areas, Anita Federici (she/her) (04:06.648) Thanks. Sean (04:21.401) similar to what is categorized as borderline personality disorder and the general field of eating disorders, because those two conditions have generally been poor responders to mental health treatment. The outcomes can be quite poor, unfortunately, and there's a stigma attached to these conditions where many mental health professionals don't even Anita Federici (she/her) (04:36.88) Thanks for watching! Sean (04:44.133) accept them as patients or clients. Is that why you have concerns about having the conversation on this podcast? I want to make sure I have the right person. Okay. That's that's why I wanted to make sure I had the right person with the right background. So can you tell us a little bit about, you know, your career, what brought you down the line to become a DBT clinician and to focus on these areas? Anita Federici (she/her) (05:05.252) Yeah, I'm smiling even before I answer that because I appreciate maybe the hesitation or the thoughtfulness in having a discussion like this. And I guess I'm pretty honored that you would think I'm the quote unquote right person. I think I'm certainly a person. I think this is a tough area and you're gonna hear me talk about why. It's complicated, but it's an area that I absolutely love being part of and so the short answer to your question would be that I Started out working in eating disorders for a number of reasons as I was becoming a psychologist in my master's years Remember, you know those long years you're doing all that work and I was working I happen to have a placement at the Toronto General Hospital's eating disorders program And I learned a lot there about what standard eating disorder treatment was at that time. And we're going back 25 years. Okay. So, you know, uh, so it gave me a front seat view of what was going on from an outpatient perspective, day treatment, inpatient, and what the leading theories, uh, were about what was going on for people with eating disorders. I would go to the conferences at those times. And. And so I'm very grateful for those years, but the evolution of how I got from there to here was really based on frustration. You used the word appalled earlier in your introduction and I wrote that down because it just, you know, and it's not, I'm not trying to judge my colleagues. I think they are also, they were doing the best they could with the information that they had at that time. And I was not satisfied with how we were talking to people that struggled. I wasn't satisfied with the way we excluded so many people from standard eating disorder treatments. So again, in my day, if you had co-occurring conditions, suicide, self-injury, if you had difficult interpersonal, Anita Federici (she/her) (07:19.024) dynamics, if you were using substances, you know, if you were emotionally struggling, you were basically excluded from standard eating disorder care. And despite efforts in my master's years to try to do more, I was not allowed to do that. Okay. So that was the first, I was unhappy. I was unhappy because I knew that if it was me in that treatment, I would have felt invalidated and misunderstood. And that was important. Then I was offered a job at the Borderline Personality Disorders Clinic at the Center for Addiction and Mental Health as I started to transition into my PhD. And I completely, completely fell in love, both because DBT is a good fit for my personality. I'm a pretty irreverent soul. I like uncertainty. I like getting into the discomfort and I'm okay with that. And DBT let me be me in a really evidence-based way. And it just was the most compassionate treatment I'd ever been exposed to. And I was trained in CBT, in FBT, in emotion-focused therapy, so on and so forth, as one does when you're becoming a psychologist. And I sat there with my advisors and I said, why on earth? Now this is going back, this is the early 2000s. I said, why are we not doing this at eating disorders? I don't understand why we don't. And so my dissertation was the beginning of that journey for me, of starting to adapt and think about what it meant to treat someone with an eating disorder in the context of a biotemperament, right? That normally would get labeled and I say quote unquote borderline personality disorder because I frankly hate that title. I just want to put that right now. I use it because we all know what we mean, but I want to be clear that it's a really not a nice way of thinking about people. So anyway, that was the birth of it. And then I could go on, but I wanna sort of pause there for a minute. And... Sean (09:23.345) Yeah, it seems like it's very similar is our exposure to certain ways of thinking or certain models and approaches to treatment. Maybe in your heart and your soul, you feel like it's, it's certainly at the very best and complete. And in some regards, it can be harmful. So your exposure to other ways of thinking about it, and your exposure to some of the science base that works then opens the door like, expand your consciousness and awareness into Anita Federici (she/her) (09:30.171) Mm-hmm. Sean (09:51.069) various ways. So one of the things that stood out to me, what you just said was talking about your inherent personality and the permission that DBT gave to be yourself. And as you notice, our name of our podcast is radically genuine, which is a high level of validation that DBT therapist really kind of adhere to. I want to get your, you know, just kind of your impressions right now, because one of the challenges I have with the general cognitive behavioral field is the CBT for Dummies approach in a way it's been kind of watered down and communicated to the general public. And we even have a hard time sometimes finding clinicians that can work here because they've been trained from such a limited model. And it's my belief that conceptualization of a case drives treatment intervention. And so let's get into, I want to get into conceptualization of someone who may be both struggling with eating disorders and that label of borderline personality disorder. I hate it as well because it's a restricted categorical diagnosis, almost like it's akin to another medical disorder. So like people will say, I have borderline PPD or I want that diagnosis, I have this, right? And it's so important to communicate that these are constructs. These are general heuristics or a way of kind of communicating. They were never designed to be like a medical disorder in which something somebody has. So we have when we have someone like yourself on here, let's just how can we communicate what BPD is in a way that is just much more grounded, also much more compassionate. Anita Federici (she/her) (11:34.712) Mm-hmm. Yeah. I think that's essential. You know, so, you know, I think one of the big things that I do in DBT or, uh, med DBT, which is an adaptive version of DBT for people with eating disorders, we can talk about that, but I think it's important to emphasize exactly, like you said, these are constructs. I like to talk to people about what they think the term means. Cause by the time they get to us, they've already heard terms like borderline or BPD. I come from a line of academics who, you know, linguists is important. So I'm like, where did the, where did the term even come from? What did it mean? You know, why was it there? You know, and I think it's important for people to understand that when we, when we use the term borderline personalities, we were really focusing on people that struggle with emotions and interpersonal, I guess you could say regulation management of. you know, for very good reasons. Some of that's biologically driven, some of that's because of the environment we've lived in and things we've learned. But it really to me is sort of an empowering way of getting to understand yourself. I'm a big believer that if you understand your bio temperament, right, if you really understand how you work and kind of what works for you, you can actually start to carve out pathways that are really effective. So for me, understanding that somebody has borderline personality disorder, whether we like the term or agree with it or not, it tells me that this is a human being who has deeply struggled with, from biologically, socially, and probably has been deeply misunderstood most of their lives. And that's a particular type of trauma. So I think it's important that the term itself is less important than what does it really mean to struggle. Anita Federici (she/her) (13:34.04) Because a lot of people still today, I just got a referral today for somebody described as manipulative and interpersonally volatile. And I thought, that is to me already, that clinician doesn't understand, right? And so what scares me, the harm is that, how does that clinician explain that to the patient, the person, right? For me, I think understanding that you have borderline personality disorder, is a source of empowerment because we can move with that. We know what to do with that and oh my gosh I actually think I can help you. Right? Versus that oh it's a manipulative, volatile, angry sort of human being. That is a complete misunderstanding, right? And watered down version. So that's the first part. I think people need to know what you're talking about from a place of compassion. Sean (14:28.482) Let me ask you about laypersons or other clinicians' idea of what borderline personality disorder is because when you throw out that term manipulative, you hear this way too often and why certain clinicians who are in the general mental health field will say they don't treat borderline. So what do you think the general clinician who doesn't have expertise in this area actually thinks of somebody who has that diagnosis? Anita Federici (she/her) (14:41.153) Yeah. Anita Federici (she/her) (14:51.984) You know, I do this in all of my trainings when I train in DBT or in personality, or, you know, and it's one of the first things I ask the group, I say, what do you, like free associate with me for a minute. Let's just throw it out there. What do you think? And it's almost always the same, regardless of where I am, even internationally. So you get terms or phrases like manipulative, treatment non-responsive, don't wanna get better, nothing works, manipulative is a big one. you know, deceptive, they're liars, they just want attention. I mean, it breaks my heart every time I hear it and I have to go there with people in order to get them where I need them. But I think you're right. The first part is that I think the majority of people still see borderline personality disorder or people who struggle with emotion regulation as sort of intentionally. trying to manipulate or cause harm to other people, which is absolutely not what's going on. Sean (15:56.497) Yeah, do you think that they can someone who is really struggling with emotion dysregulation and maybe has a history of exposure to an invalidating environment across the spectrum, even in terms of trauma, can you actually understand and treat the condition without having a background in understanding, you know, behavioral therapies or contemporary behavioral conceptualizations? Anita Federici (she/her) (16:27.264) Like you said, for me conceptualization and collaboration and informed consent is everything. So I rely heavily on behaviorism as a construct. It's helpful for me to understand why do we do things? I have to understand reinforcement principles. I have to understand what reinforces and shapes me as a therapist. Like, I mean, if you didn't have expertise in that, but that alone is also not enough. You know, like this is why to me, you have to also be well-trained in dialectical theory, which goes beyond the ability to say and in between two things. Okay, sorry. But you know what I mean? Like people are like, I'm dialectical because I use the word and, and I'm like, okay, but what does it really mean to have a dialectical worldview? Okay, so to me, that's the brilliance of what Linehan did was sort of bridging this space between understanding behaviorism and understanding acceptance-based approaches and then finding this synthesis, this ability to tolerate that there is a synthesis between these things and then developing an intervention based on that. So I guess the short answer is no, I think you need to know. Sean (17:45.053) Yeah, because the way, and the reason I say that is because the way that another person's behavior is understood by a clinician influences then how they respond to them. And so if you're viewing it as being manipulated, or if you're viewing it as being attacked, instead of understanding that this person learned something, and this has a function to it, this person's actions right now have a function. Anita Federici (she/her) (18:13.92) Yeah. Sean (18:14.125) And if you're unable to see it that way, well then, I don't think you can treat somebody who has severe emotion dysregulation. Anita Federici (she/her) (18:22.58) I agree. And, you know, because when I teach trainers, students, clinicians, I talk about, DBT is about the transaction. It's not just a focus on what is the client doing. And that's something I get frustrated with, even in publications, I say, everybody focuses on what the client does, that they're not a responder. Find me the publications that show me what the clinicians are doing that makes the treatment also untenable. And that's the space that I try to train clinicians on and also operate in myself, which is that you have to be looking at the moment by moment transactions. So if a client yells at me and I think, oh, you're so difficult and you're just trying to manipulate me, damn right that's gonna influence the way that I respond versus if I go, holy smokes, okay, not cool that you're yelling at me, I don't love that, that's not, you know, I don't love it. And you're yelling at me probably because that's helped you get your needs met. Because you're pretty, you're pretty mean right now and it makes me want to back off. Right? So that to me is what DBT is so good at. It's the moment by moment transactions between therapists and client, especially if you think about who we're treating, whether we're talking about BPD and or with an eating disorder. These are clients that have significant emotional difficulties, differences, and interpersonal difficulties and differences that when you understand that you go, well, of course standard treatments don't work. How is it possible that CBT alone, as it was originally designed, or family-based treatment, I'm thinking eating disorders for a minute, how is it that a clinician who's trained in those models, it's too narrow? Of course it's not gonna work because you're not dealing with the entire picture. Sean (20:29.609) So it's understanding that this is not who they are, but rather it's what they've become as a way to maybe cope with their situation, the way they were raised, it's their response to those situations. Is that what you're saying? Anita Federici (she/her) (20:34.603) No. Anita Federici (she/her) (20:42.796) I think this is interesting. So the behaviorist would say that personality is sort of a learned repertoire, right? It's sort of a, you've learned to be the person you are. And I think there's a difference between personality, I'm putting air quotes, I don't know if people can see me do that. So personality and coping style versus genetics and biology. Like there's certain things about you can't pick, right? Like... I am not a, I'm an irreverent person. I am not a risk taker. You're never going to find me at the casino. I don't like losing my money. Okay. I'm just hardwired. I'm like that since I was a kid, like super like over controlled in that way. But I don't pick that about me. Right. Versus I have friends that are like, they would jump out of airplanes, right. And be like, no, I just did that on Sunday. And I'm like, how do you do that? I think some people are just, we're just, our brains operate differently. We have genetic. But I don't think that's the same as what we learn and how our biology and the environment shapes how we learn to cope with the world or our emotions or the people in our lives. Sean (21:52.305) I also think that since I do believe that there's a biological vulnerability and they experience emotions fairly intensely, how they actually think about that matters and what they've learned about it. So I have an old, it was a graduate, adult graduate from a DBT program who gave me this gift at upon graduation and I have it hanging in my office and it's a picture and it has Yoda on it. Oh, I've seen that, yeah. And you know, my name is Dr. McPhil. There's a quote there says from Dr. Mick Yoda emotion. I want to get it exactly right Fear your emotions not for your emotions are your greatest superpower Because we changed the way that she thought about her emotion now say it in Yoda's voice Because that was the difference for her when she stopped viewing her emotional sensitivity as Anita Federici (she/her) (22:42.046) Hahaha! Anita Federici (she/her) (22:47.256) Yeah. Sean (22:50.889) like some symptom of a disorder that ruins her life, but rather of a gift that's provided to her. And when she learns how to respond to it effectively, then it changes everything. It enhances her relationships, her creativity, the love that she can experience in her life. And I think that's the key is when we talk about the modern psychiatric industrial complex, we view emotions as like symptoms. of some illness. And that's why I don't like the conceptualization of disorders in this manner. So if we had to come up with a better conceptualization of BPD, other than using that language, Dr. Federici started talking about challenges or difficulties one person may have, and that's real, and they require help with that. I think DBT really is effective for people who are experiencing multiple presenting problems. But what's underlying it, right, is that emotion dysregulation. You know, how it influences their actions and the patterns that are set up in their lives. But I think the key is, is that the environment often kind of shaped it too. Like they learn certain things work. Anita Federici (she/her) (24:03.56) How could you not? We've all grown up. We all have an experience of our own personalities. We all have an experience of our own childhoods. We all learned things from our parents, from our peers, from our teachers, from the culture, right? We don't exist outside of that. It's impossible, right? So we all have, and so some of us, you know, for some of us, I think our biology... you know, helps us cope more effectively. And if we have a certain biology and we have a certain validating environment, we do okay. But you know, so many clients over the years, I've thought even with my biology, if you put me in that environment, I might be exactly where you are. I might be on an inpatient unit too. Because the invalidating environment, environments that continually communicate that you know, you don't make sense, you're too much, you're unwanted. your other, whatever it is, those are so deeply damaging to the developing sense of self. You know? Right? So, yeah. Sean (25:07.329) Totally agree. Sean (25:11.581) And Anita, I started my career providing CBT E, Enhanced Cognitive Behavioral Therapy for the treatment of eating disorders. And that initial experience, although effective for some people, if I just was an expert in providing that, there was a number of people who were struggling to make progress with me. Anita Federici (she/her) (25:17.604) Mm. Sean (25:39.025) And Sean, I don't know if I've ever really talked to you about this, but I mean, we tend to learn from our clients and we certainly learn from our treatment failures. Oh yeah. So there was like, I was seeing like a trifecta that existed in my work. Someone with a history of trauma, generally a woman, sexual trauma, some form of physical trauma, the development of an eating disorder, and then severe emotion dysregulation. that influenced the development of relationships, being able to maintain relationships, which actually also then was brought into our therapy session, right? And that's what drove me down the path of being intensively trained in dialectical behavior therapy and really honing my skills to be able to identify, recognize and treat trauma. But it was DBT, Anita Federici (she/her) (26:32.973) Mm-hmm. Sean (26:35.593) that set the stage for all of those because of the manner in which we approached it. We saw skill deficits as necessary. I mean, how do you treat trauma if somebody is suicidal, cutting themselves and in an active eating disorder, right? It will not work. And that's kind of what I see as part of the harmful part of this, Anita. And I wonder if you're seeing the same thing is Anita Federici (she/her) (26:55.481) Yeah. Sean (27:05.093) Even people who come from this trauma informed perspective, they believe that treating the trauma or helping the person with the trauma will then resolve those other conditions, which are potentially life threatening. So how do you think about it? And how do you approach those cases in your clinical practice? Anita Federici (she/her) (27:10.061) Yeah. Anita Federici (she/her) (27:15.853) Yeah. Anita Federici (she/her) (27:24.296) Yeah, it's an excellent question and it's one that the field is grappling with. Like, you know, there's, I think in the next few years, you're going to see more and more publications and research around this because I know what's sort of going on behind the scenes. I agree that if somebody is, so in DBT we talk about stages, right? Stage one versus stage two work, right? Stage one work. is defined by what Linahan referred to as behavioral sort of dysregulation. Like you've got somebody that really, their life is chaotic. It's sort of like the life is on fire, so to speak, right? So they're struggling to stay alive. There's a lot of skill deficits. And really they're just struggling to cope on a day-to-day basis, right? And that's who I see. And a lot of people that I see like you have a trauma history, have been diagnosed with borderline personality disorder and have an eating disorder. Right. So the first, what I love about DBT is, is that it gives me a framework, like you said, to collaboratively and compassionately get to the big stuff. Cause a lot of my clients want to work on the trauma. A lot of them have said past eating disorder treatments haven't worked because they would not talk about trauma. DBT is more dialectical. I say, look, I'd love to get to trauma with you. I agree. I think it's a major piece of why you hurt so much and why you do what you do. I agree with you. And... If you're medically unstable because of your eating disorder, right? Your bradycardic, your heart's not working well, your electrolytes are so low, and you're in and out of inpatient, I'm not going to be very helpful for you. Likewise, if you are struggling to tolerate a little bit of emotion, I got to tell you, trauma works, not a cakewalk. Okay? Like it's tough. So I need us to be able to go into trauma. Anita Federici (she/her) (29:36.356) from a place where I know, you and I both know, you're safe to do that. So we can, I wanna set you up for success. That's how I sort of frame it. And I don't think I've ever had a client that goes, well, that makes no sense. Right? I do agree that there are providers out there who believe that all of this will go away if you just treat the trauma. I have no problem on this podcast saying, I have never in my 25 years seen that happen. I have seen clients say, I don't want to work with you, I don't want to do DBT, I'm going to go do EMDR, cognitive processing therapy. And I go, go do it, if that's what you want to do. And they come back, I just had a client a couple of weeks ago and she came back and she says, well, that fell apart. I said, what do you mean it fell apart? She says, well, I think I was too much for the trauma therapist. They didn't know what to do with my medical instability. They didn't know what to do with my weight loss. And I said, well. Sean (30:23.972) Yeah. Anita Federici (she/her) (30:36.872) I'm glad you're back. You want to talk pre-treatment again? You want to talk about how we might do everything? But I do think it causes harm when people try to dive into areas where your client's not ready to go. Sean (30:50.881) Yeah. That you actually, you're making me think of a question. Um, and, and you and Roger are very similar in terms of like you love being uncomfortable. Um, and I think that's what makes your personality is very strong and successful in this area. But, you know, not every clinician is. And I think a lot of clinicians, and this is all hypothetical. I'm not a clinician. Um, they may take on a client and then they think that they're going to be working on something. And maybe then they come to the realization that there might be some food or weight related issues that are contributing to it. So what approach should a clinician take when discussing weight related matters with a client who hasn't acknowledged that their relationship with food and weight might be impacting their physical and mental well-being? How do you do that in a way that won't jeopardize the relationship that's being established? Anita Federici (she/her) (31:33.07) Yeah. Anita Federici (she/her) (31:43.448) Sean, that's like a whole other afternoon podcast. Okay, that for one. No, no, no. The more brief answer would be one, I think that everybody should have, eating disorders are everywhere. Okay, we were in a crisis before COVID, post-COVID. If you're working with people with complex situations and emotion dysregulation, I'd have some sort of screener right out of the gate. Sean (31:47.442) Sorry. Anita Federici (she/her) (32:12.428) because chances are you are already seeing people that have eating issues or eating disorders. I think it's smart to just, just like you'd ask about substance use, like, you know, are you using cocaine? I would like to know that now, you know, but a lot of, so one of the problems is that most people don't ask. So that's one thing. So that's gonna help everybody in the longterm if we could just get a little more effective in integrating the fact that eating disorders are very prevalent. and I think should be part of any kind of intake assessment just to know. But let's say you have a client that doesn't think they have an eating disorder and says, no, but you start to realize, I think one, don't avoid it. So a lot of clinicians I talk to are like, I'm like, so here's one thing I'll say. From the DBT lens, DBTers see eating disorder, I'm talking in generalities. But many TV tiers historically have seen eating disorders as part of emotion dysregulation. And if you just treat the emotion dysregulation, the eating disorder itself will also go away. That's not accurate. Eating disorders are specific neuro metabolic illnesses. So yeah, they're related to emotion regulation and they have very specific neuro metabolic genetic underpinnings that you need to be addressing. Sean (33:41.237) Can you elaborate on that in terms of like a layman understanding the neuro biological? What does that mean? Anita Federici (she/her) (33:47.137) Yeah, yeah, yeah. Oh, I love this stuff. This is what makes me love this work. So what I mean by neuro metabolic is recent, more recent research evidence demonstrating things like people that have, we know about anorexia right now. I suspect we will see more, but right now I can only speak to the published literature. We know that for a large number of people with anorexia nervosa, There are genetic abnormalities on the chromosomes related to metabolism. What does your metabolism do? Sean (34:22.717) regulates your glucose? It's energy, right? It's the energy system. Yeah. Anita Federici (she/her) (34:27.393) It's your energy system, right? So it actually is a very comprehensive system that regulates intake, energy expenditure, how food is digested, weight regulation, certain sensory issues, hunger and fullness cues. Now think about this. You've got someone in your office and you think they might have, I'm just using anorexia as an example. This could be across other eating. immediately once I know that or I suspect that one, I'd want that person to get properly assessed. Like, so if I'm not capable of assessing that, that's okay, but I'd rather say to my client, I'm kind of worried. Could we bring in someone who could, because it's like finding out that your client is using cocaine and you're like, I'm not really a substance use person. I'd be like, let's, what, what? Sean (35:12.257) Yeah. Anita Federici (she/her) (35:17.272) You know, so I think that you have to lean into it and make sure you understand what's really going on. Because if you have, let's say there's anorexia in this example, how fascinating is it to think, and this is just one of many neuro metabolic markers, you've got someone sitting across from you whose genetic makeup makes it so that eating and regulating weight is actually difficult. If you try to treat that by applying DBT skills and strategies, that might help, but you also have to understand what it means to have a different metabolic system. So I'm going to go back to Roger for just a second. When you talked about, you know, our collective dissatisfaction with certain treatments, one of the things that I am passionate about is that standard eating disorder treatments don't... I don't think adequately appreciate what it means to walk into, let's say, a day treatment program when my body is going to metabolize food differently. We've always been like, oh, that's your eating disorder. You just got to push past it. And I'm like, push past it. Your metabolism is working differently. This is now, this piece has actually shifted how we think we should feed people. Traditionally, an eating disorder, it doesn't matter. You just eat this way, right? Sean (36:49.525) Oh, I'm so I'm so glad you're going here. Um, because it's almost impossible to find someone who's willing to have this discussion. Um, alright, so you're bringing up things that we've talked about on this podcast. Previously, we actually had Dr. Christopher Palmer on this podcast, who is talking about the role of metabolic illness, brain energy, brain energy, and I've been refeeding anorexics for Anita Federici (she/her) (36:51.928) Okay. Anita Federici (she/her) (37:06.517) Nice. Yeah. Sean (37:18.337) 15 years at this point. And so I've seen the standard struggles. I see what happens when someone becomes hyper metabolic. And I see people who are on specific diets where we're unable to restore weight, like vegan or vegetarian. And then I see how shitty our food source is. I see like the standard crap of processed food that are delivered to our country. And then there's a lot of professionals who say, Anita Federici (she/her) (37:31.971) Yeah. Sean (37:48.093) You know, all food is good food, right? And I don't personally believe that. So if you believe that there's an opening here that we have to find the right foods for someone who may be sick, metabolically ill, vulnerable to eating disorders, what do you think those foods are? Anita Federici (she/her) (38:04.304) Geez, geez, these are huge questions. I think that I try to get, so there's a difference between talking about food in the general population versus people that struggle with eating disorders. So I'm not trying to, what I am gonna talk about is, I'm thinking about my clients, right? I'm thinking about, so on one hand, I think that the research on neuro-metabolic underpinnings, which also includes sensory issues. You know, some people have oral sensitivities. You know, there's all contextual issues. There's so much that goes on in terms of what it means to have an eating disorder. I actually think it would be more helpful for people if we helped feed them in ways that might actually be more in line with their neuro metabolic underpinning. So an example of that would be There's a publication, Cindy Bulick, Nancy Zucker talking about, you know, feeding people instead of like, look, everybody has to eat this way. This is what it looks like. Why not feed them in an anti-inflammatory manner? Because that's actually in line with the sensory neuro metabolic, again, dysregulation, right? As opposed to everybody eats the same way. And I think That's one piece. I don't like to get into discussions about like good food, bad food. Like someone with an eating disorder, that can be a dangerous area to get into. Like I'm more interested in how can you feed your body? How can you feed yourself in a way that you can have a life worth living? Sean (39:47.421) So instead of putting things in categories of good food or bad food, and we understood nutritional deficiencies, if we understood how the brain requires certain foods for energy, especially like maybe healthy fats, and that this could actually improve recovery quicker and ease some of the suffering that takes place during weight restoration, that Anita Federici (she/her) (39:52.301) Yeah. Anita Federici (she/her) (39:56.11) Mm-hmm. Anita Federici (she/her) (40:01.71) Yeah. Anita Federici (she/her) (40:10.7) Yeah. Sean (40:14.549) then we're taking advancements in this field. Because now we're integrating nutritional science, metabolic health on neuroscience, and we're implementing it in a way that is going to allow someone to heal faster, quicker. Now the problem with anorexia, and I'm sure this is something you experience, is that once you become so nutritionally deprived, your brain becomes starved. Anita Federici (she/her) (40:42.133) Yes. Sean (40:43.305) then your response to food is different than the average person, right? And there's probably an evolutionary reason for that, right? What is that response to the food? So I was gonna get to this because Christopher Fairbairn was conceptualizing eating disorders as an over-evaluation of shape and weight. And Anita Federici (she/her) (40:47.632) That's right. Anita Federici (she/her) (40:52.886) Absolutely. Sean (41:08.697) I didn't agree with, it's not what I was seeing in clinical practice because so many people involuntarily became anorexic. Okay. Right? And I'm sure you've seen this, like someone, I'll give, it's a trauma response, lose their appetite then they become anorexic. One client had their, um, some teeth extracted and had a dental emergency which led to they couldn't eat for a couple of weeks. I remember. No history of an eating disorder. Anita Federici (she/her) (41:18.168) Yeah, they don't agree with that. Sean (41:33.641) You warned me at one point when I was training for a marathon, I lost like 18 pounds and I was super skinny and you said, Hey, be careful. Yeah. Just because it could trigger. Anita Federici (she/her) (41:41.132) Be careful because if you have the genetic, so we often say genes load the gun, the environment pulls the trigger. So you may not intentionally, like nobody says, oh, I'm gonna have bulimia. Nobody says, oh, I'm gonna have arfid or anorexia. It's, you know, it's that there's a huge genetic push. And so for some people, there's enough protective factors and it never develops. other people, like you start running for a marathon and all of a sudden that your biology responds to that deprivation, weight loss, it just, you know, Cindy Bulick, I love her work, you know, she talks about restriction and anorexia and she says restriction is experienced differently for people that have this biology, which is that it is soothing. So for most of us, when we don't eat, it's not comfortable. We get hangry, we're upset, we don't like it. We wanna know where the food is, right? People that are genetically predisposed to having anorexia, that deprivation is experienced as soothing. And she describes it as like an anxiolytic. And she says it soothes an unsettled biology. Sean (43:03.177) And we see this in some of the ketogenic diet research, where when someone goes into ketosis, there's like a focus, a decrease in anxiety. You almost feel caffeinated. Improved mood, you know? And, you know, that's not, of course, that's not everybody, some people get really sick. You know, they hate, you know, they need to eat food constantly, it probably has something to do with their metabolic system. But I talked about this on the podcast, you know, I'm kind of crazy in a lot of ways. I... Anita Federici (she/her) (43:06.729) Oh yeah. Anita Federici (she/her) (43:15.524) Yeah. Sean (43:31.145) deliberately calorie restricted for a period of time to know what my clients were feeling because I was treating anorexia. So I did it. I deliberately calorie restricted, lost a lot of body fat. And then it was hard for me to put it back on for two reasons. One, I started seeing food differently. I don't really need that. I started to see my body differently. I am you're not supposed to have much body fat at all. Anita Federici (she/her) (43:35.6) We'll see. Sean (43:59.441) and I felt like there was a control mechanism over it. Oh, like I can live better by restricting this. Like it got into my head if I didn't know better. If I wasn't- I think it still gets in your head a little bit. If I wasn't educated on it, I wouldn't have restored my weight. Because other thing, I mean, my energy was down. Other things were affected by it. But I could at least get into the mind space, the brain space of somebody who was severely, calorically deprived. Anita Federici (she/her) (44:08.313) Thank you. It's just... Anita Federici (she/her) (44:26.912) And how did the environment respond to your weight loss? Sean (44:31.025) Well, my mom, my wife just got pissed at me. I mean, she knew what I was doing. And I've experimented with different things in the past. Yeah, no, she just got angry with me for doing it. I rationalized it, why I was doing it. And I wanna understand what my clients are going through. And I wanna see how my body reacts. There was a lot of reasons that I was doing it. But once you get to a certain place when you've lost the weight, I mean, I was weighing myself every day. Anita Federici (she/her) (44:36.559) Okay. Yeah. Anita Federici (she/her) (44:43.3) Okay. Sean (44:58.281) You know, multiple times, like checking the weight. You become obsessive with it. Anita Federici (she/her) (44:59.577) You are. You are, this is, you know, this is that Ansel Keys study of the 1950s, right? You know, the sort of, which, which I, you know, I always highlight to my clients, I'm like, listen, Ansel Keys did semi-starvation in this group of men, right? Do you know what the semi-starvation caloric amount was? Do you remember that? It was 1560 calories. You, like. The average recommended healthy diet from all the people on the internet is like you should be having 12 or 13. I'm like they called semi-starvation 1600 calories a day for these guys and they showed you are describing what they experienced. So this is what's important is that starvation is starvation is starvation and it doesn't matter what your body actual weight is. This is one of the controversies right? It doesn't matter if your BMI is 15 or 24. If you if you're in starvation mode you're going to have the same experience. Sean (45:55.241) Maybe this is an appropriate time to transition to something I was hoping we would talk about. Barclays has forecasted the obesity drugs within that GLP-1 drug class. It's like Ozempic, Wigovia, and Jaro to reach 100 billion globally by 2030 and could be up to $200 billion. I understand little about how these drugs work, but it seems as though you end up starving your body because you're not really consuming. You don't even have the cravings in there. Anita Federici (she/her) (46:23.86) Yeah, you are. That's exactly what happens. Sean (46:25.789) Yeah. So what are the risks that anybody who should be, you know, who may be considering these drugs is I was in Los Angeles and I heard people talking about it so carelessly, like, oh yeah, the melt just, the fat just melted right off of me. And, and I was always like, boy, why, what's going on there? So how should people be thinking about these before they even consider it? Anita Federici (she/her) (46:49.245) Yeah, I... Anita Federici (she/her) (46:54.28) I think that two things that come up, that's why I'm sort of hesitating for a moment, where do I wanna start? I mean, one is of course people are gonna run to a medication like that, that is the effect of diet culture. So I wanna be careful that to me, the responsibility is not on people, it is on pharmaceutical companies, it is on physicians who prescribe. to be ensuring that there is what I call informed consent. I can't control the ozempic, you know, or, you know, I can't control what's happening. But my experience so far is two things. One, most people have not received informed consent about these drugs. They are oversold the promise of weight loss, which is what diet culture does. It doesn't matter. It's just now the new flavor is this. It was bariatric surgery a bunch of years ago, and now it's this, right? It's the same thing, different flavor. So it's an oversell and a minimization of the risks and long-term effects. So that's one thing that's happening. So I would argue that ethically, that's not having informed consent is an ethical issue. Two, I think I wish people understood more what exactly Roger, you were saying, which is that it doesn't matter why you're losing weight. It doesn't matter if it's because you're coming from a war-torn country, if you're on a drug like Ozempic, or if you have an eating disorder, when you drop significant amounts of weight quickly, and you drive your body lower than where it genetically wants to be, it's well documented that you're going to have a whole host of psychological and physical consequences to that. Sean (48:42.717) So it could trigger an eating disorder for someone who previously does not. Anita Federici (she/her) (48:46.716) It will trigger an eating disorder if you have the genetics to support that. It is causing relapses. I have a number of clients who've reached out to me over the last year, whose doctors have prescribed Ozempic claiming that it helps with body image, that it's a frontline treatment for bulimia and binge eating disorder. None of these things are true. Sean (48:53.65) Okay. Anita Federici (she/her) (49:12.996) But can you imagine if you're somebody that has grown up being weight and shape based, bullied or teased, being rejected by culture because you live in a larger body, you know, nevermind gender and, you know, sexual, you know, all these different pieces, like there's so many pieces here. And then you walk into your doctor's office and they recommend support prescribed with the promise that this is gonna solve a whole lot of your problems. So now I have clients reaching out to me, who have written things to me like, I'm a mess now, my eating disorder is back in full blown status. But the problem is that they'll say things to me like, and my eating disorder loves it. And my heart, I can't like, of course it does. Sean (49:56.558) Oh. Sean (50:04.261) I think we're definitely gonna have to get some people on this podcast to talk about these, the risks of drugs like this. We do talk about how the pharmaceutical industry has really hijacked vulnerable people and our physicians by underestimating the risk of what happens when you introduce a medical intervention that changes the way the body is naturally designed. There you go. I wanna add something here because I've been trying to read into happens with this drug and they're even talking about it in financial news is that when someone goes on this drug, it's like 25% or more of the weight loss on these drugs is muscle. Yeah, so you know, a patient clinical trials aren't really strong that they that they actually demonstrate weight loss in the in the manner that we would look for which is restoring health. Yeah. And then long term weight loss. So this is what they're saying like a patient needs to double down on resistance training and modify their diet to increase protein. So if you were to separate yourself from that, let's say maybe you have obesity as a problem. If you know you're going to go on a drug and you're going to have to double down your resistance training and change your diet, why not work out, change your diet first, commit to that and you'll probably see some significant improvements. What am I missing there? Well, that's logic and there's reason. But there's other things that are important there A lot of people who have who are obese are pre diabetic have insulin resistance. And so their diets have been heavy on processed sugars and carbohydrates. And you require like an immediate intervention. This is some of the things I've also seen, unfortunately, with the development of bulimium binge eating is and that's why it's so important to stay away from these labels, but rather to have a real thorough evaluation of context. And each person is different. Anita Federici (she/her) (52:03.268) Mm-hmm. Sean (52:03.441) I've seen people become bulimic because of the type of foods that they eat and their blood sugar drops. And then they continue to like become almost dependent addicted on these foods that give high sugar, high carbs. And then the discomfort leads them to vomit for the immediate relief of the fullness, right? And they need diet interventions, effective healthcare diet interventions. And it's not always emotionally driven. But then you'll find another case where there's a lot of emotional or cognitive factors or learning factors that are associated and then it's a coping mechanism for other things. So there's such a diversity of each individual person and what they're going through and that's why effective mental health care can't be so generalized. Anita Federici (she/her) (52:42.488) Yeah. Anita Federici (she/her) (52:49.42) No, no, there's so many pieces. I mean, I think that, just to go back for a second, and so when it comes to, you're right, trying to solve a complicated set of syndromes, patterns, whatever, with a medication is really inadequate and has poor oversight. When you talk about millions and billions of dollars, so the other thing too is that you have to remember Like you said, weight loss, regardless of the reason, you don't just lose weight in certain areas. You lose muscle mass, right? The heart is a muscle. So when you think about why do people with restrictive eating disorders over time have higher mortality rates? Because that kind of weight loss or sustained low weight does over time damage the organs. So even if that's induced by Ozempic, you're still putting strain and changing even the heart. function, the cardiac functioning, right? So weight loss is not as innocent as everybody thinks it is. I think that's an important point. Another huge factor related to drugs like Wigovia and Ozempic is the higher rate of gastroparesis. So this is really problematic because it can be life-threatening for one. It's a very painful condition in which the metabolic track, the digestive track slows down. It can slow down so much that it can become incredibly painful and life-threatening. People with eating disorders are already at high probability of having gastroparesis. So if you give them now a drug that is known to cause gastroparesis, I mean, that is a lawsuit minimally waiting to happen. And I think it's unethical care. So again, there are these physical consequences that are minimized because diet culture is so embedded as you have to lose weight to be valuable on this planet. And it doesn't really matter if it might kill you in the end. Anita Federici (she/her) (55:03.076) And it's a mess. It's a mess for people with eating disorders and it's a mess for people without eating disorders. Sean (55:09.717) So let's talk about what works. And we've been touching on a lot of different things. We've kind of introduced like conceptualizations from a DBT perspective and came all the way down to OZEMPIC. Sorry. Let's start with low weight anorexia. What works, Dr. Federici. Anita Federici (she/her) (55:20.568) Hehehehehehe Anita Federici (she/her) (55:28.82) I think you know the answers to that. We don't know. But I have more to that. What I mean by that is there isn't one, there isn't an evidence-based, this is how you treat anorexia. Outside of weight restoration, okay, so there's, there are published research on, you know, CBT can be helpful, interpersonal psychotherapy can be helpful. I'm a big believer, obviously, you're gonna hear me talk about med DBT, but we have to be humble enough to recognize that we don't have sort of a very good treatment for adult anorexia. Family-based treatment for adolescents with anorexia has a better, slightly better outcome, but that's because you've got parents that you're empowering to feed their kiddos so that they don't, you know, you got a bit of a captive audience. It's like the parents become the day treatment setting. Sean (56:28.437) So yeah, what we've learned from that is one of the things I do know, like the one way I can answer this question with absolute certainty is one thing predicts positive outcomes in the treatment of anorexia, and that is actually early weight gain. So if we know that early weight gain does at least predict the likelihood of a positive outcome down the line, don't we at least in the first month or the first six weeks? Anita Federici (she/her) (56:47.565) Hmm Anita Federici (she/her) (56:58.468) Yes. Sean (56:58.781) have to demonstrate that these people, you know, that there is a plan in place to have them start eating more to start gaining weight. Anita Federici (she/her) (57:03.716) Yes. Anita Federici (she/her) (57:08.368) Okay, you like being uncomfortable, right? Okay, good, good. Okay, so yes and no. So what I mean by that is, yes, if you look at the literature on FBT or CBTE, they will say that, you know, really in the first four weeks, if you're not seeing trends in weight gain and in behavioral stability, the likelihood is you're not gonna see a great response if you stick with that modality. Sean (57:10.25) Yes. Anita Federici (she/her) (57:34.344) Okay, so yes, if I'm meeting someone for the first time, they've never had any eating disorders treatment. I normally would say, look, the treatments that have the most evidence base, let me go back to that, but the treatments that have the most evidence base would be CBT or CBT and FBT. If you've never tried those, You might want to simply because it's hard to know exactly who's gonna respond and not, but I can tell you that within the first four to six weeks, if you're not responding, the likelihood this probably isn't great for you. Now, because when you start to get into other treatments, they're expensive, they're time consuming, I'd hate to force someone to do like med DBT, and then they go, well, Adida, I could have just done CBT with Roger, and maybe that would have worked. Like I want... I think people need to have choice and understand what the evidence is. Now, who is CBT and FBT designed for? This is the other thing that I look at. You look at the published literature, two things are important. General response rates to those treatments are about 50%. So about 50% of people give or take the research study, but I'm going averages. Generally, 50% of people with anorexia bulimia will have a good outcome with CBT or FPT. That means that about 50% will not. Anita Federici (she/her) (59:02.85) Who was CBT made for? Anita Federici (she/her) (59:07.912) So CBT has been made for, Sean, are you gonna answer that? Do you know the research? Sean (59:13.753) No, I do not know. But you're making me think of like, when you look at the 50%, what are the underlying commonalities within that 50% that succeeds, regardless of what the modality is? So I've deep dived into this. I wanna at least add on to what you said. So first of all, as we talked about before, there's some flaws in the public literature. These are... Anita Federici (she/her) (59:14.896) I'm going to go to bed. Anita Federici (she/her) (59:26.212) This is a very good question, Sean. Roger? Yeah. Sean (59:39.909) standardized treatments, you have to follow a specific protocol, everyone's given the exact same thing. So yes, that's always going to limit the effectiveness because as we just talked about, everything is individualized. For bulimia, CBT is the effectiveness for bulimia CBT is higher than 50% and pushes closer to 60%. Still 40, you know, 40% in a in a Anita Federici (she/her) (59:46.468) Right. Sean (01:00:08.177) in a trial are not going to respond to that type of treatment. But those, you know, those trials are like 15, 16 sessions. So to me, it's taking, right, what do we know? What are like, what's the key ingredient? Like, what's the mechanism of action that exists in this therapy? How can we extract it and apply it to this individual person that's in front of me with motivation, with support, with skills, with potentially, you know, use of things like Anita Federici (she/her) (01:00:24.259) Yeah. Sean (01:00:36.765) chain analysis really well, because you can help understand the context. What if you add in coaching? You know, you add in coaching calls to... Anita Federici (she/her) (01:00:43.756) Now you're MedDBT, but that's not CBT per Fairburn. That's not Glenwall or CBT. So what I'm... Sean (01:00:50.408) It is not. Sean (01:00:53.949) Right, it is not. Yeah, but we can't treat that. We can't treat from a standardized, manualized-based treatment. We have to pull from the literature to be able to develop a treatment plant and a type of treatment for the person. Anita Federici (she/her) (01:01:04.205) A3. Anita Federici (she/her) (01:01:08.396) I agree and what I would say is that I think that those standardized treatments exist because I think, I don't think, I know that they work for certain people under certain conditions. That's all. They're not for everybody. But... from a public system perspective, from a how do you train people, I understand how they've evolved, because I say, well, the reality of a public system is they're not gonna be as nuanced as me and you, they can't be, right? So there's a whole, that's that whole piece. What we do know is that, as Sean, you were asking, who doesn't respond? So first of all, CBT and FBT exclude people that have co-occurring suicide. Traditionally, if you look at any of the publications, they exclude, they exclude all my patients, they exclude co-occurring suicide, self-harm, substance use, psychosis, mania, what am I missing? I don't know, you name it, right? Some of them will exclude recent hospitalizations. So, you know, FBT is the same. Some FBT studies will even exclude people that have already tried FBT, which I'm like, well, that's a particular type of person who's coming back. Sean (01:02:00.693) Yeah. Anita Federici (she/her) (01:02:21.228) Right, so when you look at who the treatment was designed and tested on, I see, well, but that's that group of people. So great, you've got a treatment for people that probably have a primary eating disorder, less comorbidities, sometimes the first time out into treatment, you know. The minute that you add in people that have substantial trauma histories, co-morbid suicide self-harm. What I get upset about is that we put them into these treatments, right? Whether it's outpatient or day treatment, we put them into CBT-based, FBT-based treatments that were never built for them, never tested on them, never designed for them. And then we go, oh, they're treatment resistant? Oh my gosh. And now you know what scares the hell out of me is made. medical assistance in dying. So here in Ontario, right? So now you've got these people that don't. Sean (01:03:24.085) So this is where we're starting. Yeah, let me jump in there. This is where we're starting to get into some differences in healthcare. And actually, I think differences that might exist in the systems in which Dr. Federici and I conduct our work. So I noticed some of the differences. This is like United States and Canada? Yes. Okay. So can you tell our listeners, because we do have a large audience for the United States, of course. Can you tell a little bit? Anita Federici (she/her) (01:03:29.718) Yeah. Anita Federici (she/her) (01:03:44.865) Yeah, yeah. Yeah. Sean (01:03:53.386) to our audience about how mental healthcare is actually delivered in Canada, in your system. Anita Federici (she/her) (01:04:01.001) Yeah, so, and I worked with Dr. Lucine Wysniewski in Cleveland, Ohio for several years. And so that was a really helpful way of understanding better some of the differences. Here in Canada and in Ontario, we have provincially funded programs. Different provinces have different. degrees of it, but there's provincially funded access to mental health care. So here for most people, if you have an eating disorder, let's say in Ontario, Canada, most people are going to access services through the publicly funded system, which means that they are treatments delivered by the hospitals that are largely medically based and that rely heavily on CBT or FBT. They are group-based predominantly. I don't want to, like, there are some outpatient options for sure, but that's the first layer. Sean (01:05:02.229) So this is why I think we're using somewhat different language here, because in your country, you're pushed to provide these standardized treatments widespread, so you're using like, well, CBT this or CBT that, where what we're doing and everything we're doing with our training is that we are talking about individual case formulations, we're pulling from the literature on what interventions might, in a collaborative way, be useful. Anita Federici (she/her) (01:05:05.846) Hmm Sean (01:05:30.341) And how can we adapt that to the individual where the UK and Canada, and this is where I get a lot of this kickback, their idea of what CBT is, is much different than mine, because they're considering these standardized, these manuals for the most part, that get widely applied to everybody. And that's just not what we're doing. Anita Federici (she/her) (01:05:48.496) Roger. Anita Federici (she/her) (01:05:53.22) Can I, two things. I left the public system a number of years ago because I could not, it was just so out of line with my values in how I wanna work with human beings. I'm super grateful for my time in the public system. I have very good colleagues that are trying so desperately hard to change that system. And it is deeply flawed and limited. And one of the things that's happening in Ontario right now, there've been these new standards. that are being published and they are basically saying that you can only do manualized CBT and FBT and I am very concerned about that recommendation but you're right here if you're in the public system that's what you're going to get and it's defined a certain way and it and we're they're actually discouraged from won't get funding if they do not deliver per the manual. Sean (01:06:48.285) Yeah, which has always been my concern about government run healthcare, and why I've kind of opposed these ideas in the United States why we've kind of restricted this we don't want to in any way take out the independence of the clinician. And when you in any way stifle the independence of the clinician, you have to do something a certain way based on guidelines or standards, which is exactly what we're seeing in since the Affordable Care Act. Anita Federici (she/her) (01:06:51.648) Oh yeah. Anita Federici (she/her) (01:06:57.101) Yeah. Anita Federici (she/her) (01:07:13.626) Yeah. Sean (01:07:14.889) and what we're seeing in our medical systems, the fast food care style of healthcare delivery where people get something quickly, efficiently, cost-effectively, but it is not effective. And then it's just like 50% at best of somebody will respond sometimes much worse. Anita Federici (she/her) (01:07:25.296) Thank you. Anita Federici (she/her) (01:07:33.873) I am with you on that a thousand percent. The problem though, here in Canada, and this was different when I worked in the States. So then you have people like me that have moved into the private sector, right? So I run a clinic where we operate much like you do, right? Where my colleague Lucina and I have developed MedDBT, which is designed for people who... you know, have emotion regulation difficulties in the context of a severe and enduring eating disorder and so on and so forth. And it's very much individual conceptualized, dialectical, I love it, my heart loves it. It's just, ah. Here's the kicker. In Ontario, if you want that treatment with me or my team, it's going to cost you quite a bit of money because the cost of paying the therapist to... do individual MedDBT, do phone coaching, do skills. I mean, that adds up every week. So you're looking at someone for six months, let's say it pays, I don't know, let's say $16,000, $20,000. Right? Most, so when I worked in the US though, we were able through the different insurance providers, we were able to actually get our MedDBT program covered for six months. So people could. could access these novel treatments, where in Canada, we don't have that. So there's this massive gap here between the public, manualized, rigid, you can only do it this way, and then the public private system, which is really quite where I would want everybody to be, but it costs a lot of money. Sean (01:09:23.133) Yeah, I guess the flip side of that would be when it comes to dialectical behavior therapy, we as a center, do the full model. So there's coaching, there's the consultation with the other clinicians, but I don't I don't believe that every other center in the area, they may claim to be dialectical behavior therapy, I don't believe they're doing that. So that's the flip side is someone may choose and say like, Oh, I really need to find dbt and they'll find a center. And then they're not getting dbt. And they don't know as a client, you don't really know. Yeah. Anita Federici (she/her) (01:09:32.653) Yep, same. Anita Federici (she/her) (01:09:39.584) That's it. That's a whole other conversation. Anita Federici (she/her) (01:09:49.765) That drives me nuts. Sean (01:09:52.465) Yeah, that Anita Federici (she/her) (01:09:58.008) Um. Anita Federici (she/her) (01:10:06.814) like them. Yeah. Anita Federici (she/her) (01:10:17.456) Because there's only one person, yeah. That's the same here. Like everybody's got a pretty website and a pretty Instagram page, and they all say they do DBT, or they all say they treat eating disorders. But then when I meet the, I'm like, well, actually you've never had DBT. You know, you've never had phone coaching, you've never, and again, a lot of the skills they offer is like, well, we're doing a 12 week skills group. I'm like, what, what evidence, I don't, you know, so, so I get protective of clients. who of course they're gonna be attracted to something that's lower cost. That's an issue, right? Like many of my clients don't have the money. They're not well, they can barely work. They're in and out of the hospital. How are they gonna come and afford me and my team? And I say, look, I need 20,000. I've had a student clinic, but at the end of the day, these are big treatments that require a lot of therapist's time, right? So the therapist, I have to pay them, like even if I don't break even. it's still a lot of money, right? And so that's a major issue for clients, right? And then, so here's the issue now that I've been involved with is this kind of transition now to made, and we don't have to talk about it, but the piece for me that's important is that you have therapies that were not designed for certain client populations, you're forcing them into said treatment, they obviously, surprise, don't respond. They're seen as severe and enduring. They're seen as treatment resistant, which is what BPD used to be back in the day. And now there's this, in Ontario in March, if you have a mental health disorder, if you have an eating disorder, you can apply for MADE, medical assistance in dying. Who's most vulnerable? It's the same people we're talking about today. They can't afford the treatment. The treatments they've had don't work. They're deemed severe and enduring. Anita Federici (she/her) (01:12:21.512) Many providers are burnt out working with them. So what they say to me is, I don't wanna keep going, Anita. And I swear it's what keeps me up at night because I think the made discussion is part of all the stuff we've been talking about. Inadequate care, poorly funded access to really good, novel, integrated, compassionate, collaborative care for people. Sean (01:12:53.725) Now, you know, when we talk about something like that ethically, this is a challenge because we've been venturing into different areas on this podcast and trying to make sense. You know, one of the things I'm very clear about on my social media is that they want you sick and dependent. You know, I say this quite often and what I mean is about the sick care system, the allopathic model in the manner in which it treats Western societies, it's very clear that by all available evidence, you know, everyone is getting much, much sicker. Anita Federici (she/her) (01:12:53.749) Yeah. Sean (01:13:24.061) life expectancy is decreasing, our mental health is worsening. So everything that society is doing, governments are doing in response to the challenges of living in our modern culture, is worsening the conditions. And now you create a government program that allows for assisted suicide. And it just brings up the answer to the questions, what is the, you know, the depopulation movement is pretty well documented those who are in positions of great power, the top 1% of the top 1% and the, the world economic forum is talking about the harms of, uh, overpopulation on our planet, on a number of other things. And you just, some of these policies are really concerning morally and ethically. Yeah. Well, you think about DBT. I mean, a lot of people that enter into that program have attempted suicide or have just suicide diet, dietality and now you're saying it's okay. It's time to go. You're right. Like how do you come to that? How does, how does it get to that level where you just help them commit suicide? Anita Federici (she/her) (01:14:31.888) I can see how it gets there because the majority of providers, the majority of the world doesn't really understand what's going on for folks. Again, you asked me, Roger, at the beginning about how the average person or even provider might think of even something like borderline personality disorder, and it's still quite pejorative. Right? Yeah. You know? And I say, well... If that's the way people see it and they say, well, you've tried treatments. I say, but they've never had access to really good, like they'd never got to sit with Roger or me, not that we can solve every problem, but geez. You know, so what happens is this kind of collective hopelessness, this sort of collective giving up and it's heartbreaking. And I just, my colleague and I just, we are in the middle of analyzing 340 responses. to the proposed criteria for anorexia nervosa. There's proposed criteria on the table. And we are gonna present our findings in New York at one of the conferences in March. But I can tell you that people are very upset about what's happening because it stems to all the things that we've been talking about today. It's not that, like, look, I can't answer, like even as a DBT-er. I can't control at the end of the day whether someone's going to take their life or not. I don't have that power and it's not mine to make. But if you want to build a life worth living, I'm your person. I'll help you do that. Damn right I will. Sean (01:16:04.009) Yeah. And it, and to your point, you know, what, what drives suicidality hopelessness is one, right? So when someone believes that they're in such intense emotional pain, and there's no way they can feel better. They're just looking at a life of suffering that's temporary. And then a burden to other people, you know, that is what drives suicide is that desire for relief. And in DBT, I believe so much in it. Anita Federici (she/her) (01:16:32.281) I know. Sean (01:16:33.109) but I also believe in myself, that we will sit down with somebody who wants to die and we'll use what's called commitment strategies and you know, Nina's well aware of this. And I will get somebody to commit to me that they will not make an attempt on their life for a period of time. Sometimes it's that first six months of the program. And I... Anita Federici (she/her) (01:16:54.915) Yep. Sean (01:16:56.341) 100% believe that if they're willing to do other things, to change the way that they think about themselves, what they're experiencing, their life, to use the coaching to get through difficult moments, to develop a relationship with that person, that after six months, they're not going to see their life the same way. They might still be in a lot of pain and might be struggling, but they, after six months, will be open that, hey, there is a path for me to live differently. that there's a new way that I can live my life, approach my life, approach relationships. There's a potential for joy. There's a potential for purpose. And then the second six months, you know, is where some of these skills and this way of thinking begins to solidify itself. Being able to apply radical acceptance, face past trauma, to actually live life where you're, you know, you're not abusing substances or you're not cutting or you're not binging and purging every day. Anita Federici (she/her) (01:17:33.858) Yeah. Yeah. Anita Federici (she/her) (01:17:54.82) Mm-hmm. Sean (01:17:57.025) It's open this path to healing and it completely changes their perspective. But again, how many people are getting that kind of comprehensive care? They're not they're getting this bandaid, this drug, some general talk therapy with a label to it, CBT, DBT, that doesn't meet any of the key components that make that therapy most important and most effective. And then bottom line, who's the person you're working with? You know, are you working with someone who's doing a job? Or are you working with someone that this is their calling? That this is their purpose and they spend their life learning and caring. And that's why they feel like at least partially here, let's do this. And it's not work, you know, and that makes the difference. Anita Federici (she/her) (01:18:31.738) Yeah. Anita Federici (she/her) (01:18:42.88) You know, you reminded me of a couple things. One, Dr. Matthew Nock, gosh, I've got his name right. There's not a lot of predictors of completed suicide, actually, like actual, like that is a predictor. I mean, you know, he had a three-part model and I can remember the first two right now, hope it comes to me, but one was hopelessness, one was access to means. So you've got people who are vulnerable because they're going to be, people feel hopeless themselves and the providers feel hopeless and then now they have access to a socially sanctioned means. I mean, I'm very scared for the people that suffer. And like you though, I'm out here talking to you because I want people to know that there are other ways of working. you may not be able to access and that's the problem. That's what a lot of us are trying to do. I'm like how do I how do I get more people to access things like dbt? That's hard right because what people will say to me is yeah Nita that's great but I can't access it. I'll never have the money. It's not available in the public system. I mean and just you know our one of our publicly funded big dbt programs led by Dr. Shelley McMain which is an outstanding program. There is a two-year wait list. to start DBT and the waitlist only opens once a year on one day and that's it. So. Sean (01:20:15.905) And this puts things in the perspective for me because I have a strong social media presence on Twitter. And I don't always talk about DBT therapy on Twitter, mostly don't. But when I do, I will get some real negative responses from people from Canada and the UK. And they're describing DBT in ways that certainly probably reflect that a poor therapist, it's not necessarily the treatment. Anita Federici (she/her) (01:20:21.56) Hmm. Anita Federici (she/her) (01:20:31.328) Yeah. Oh. Anita Federici (she/her) (01:20:43.442) I know. Sean (01:20:44.761) One thing you see out there is about coaching calls. So I got this one person on social media goes, when I went into DBT, I get punished for being emotional. And I said, well, tell me what you mean by that. I was suicidal and I cut myself and a self-interest and I was in a lot of distress and I was a little pain and they took away the coaching for 24 hours, right? Anita Federici (she/her) (01:21:13.156) Right. Yeah, yeah. No, no, yeah. Sean (01:21:13.617) No, that's typical. Is that? Yes. Now, there's good reasons for that, but it has to be agreed upon and discussed upfront. Right? And collaboratively agreed upon, you're talking about why out of a place of compassion and to help that person. Because you have to train somebody to reach out before they enter in the problem behavior. You're trying to get somebody to be skillful in the way that they manage their emotions. And as we were talking about before with behaviorism, There are some people who have, when they respond to the emotions in the moment intensely, that's the end and they act in that way, like whether it's an attempt or they're, you know, they're self-injurious, that's the only time they're getting some sort of nurturing or love from their environment. It's been so it's been conditioned, right? It's been reinforced, it's been conditioned. And we're trying to say, hey, this isn't going to work for you. This is going to cause you more pain, more suffering. But you reach out. Anita Federici (she/her) (01:21:57.444) Yeah, well there's that reinforcement, right? Yeah. Sean (01:22:10.473) before you enter in this, and we talk about how you can apply some of these skills, you're gonna get the best of me, you know, it'll be compassionate, it'll be it'll be you'll, you'll get understanding, and we'll develop a plan together. And then when they successfully implement it, then you praise it. And then you're excited about it. And you know, and you're creating a new paradigm in which the way you respond to your emotional pain. But if it's Anita Federici (she/her) (01:22:24.32) Yeah. Oh, yeah. to. Anita Federici (she/her) (01:22:33.032) The thing is, I sit here and I'm like, I could work with you all day long, we're on the same page, it's beautiful, I wish... And then I sit there and I go, almost no one in the eating disorder field, or not the feel like clients would get this kind of intervention unless they specifically find... And again, the thing that I do is I blend, right, DBT with what we know to be true about the treatment of eating and... weight and all that kind of stuff. That's what med DBT is all about. And so you're talking about pre-treatment work. You're talking about deep, genuine commitment. You're talking about a level of respect and collaboration with your client. You are talking about strategies that are nuanced and you can't manualize them, right? Like you can't go, now you say this, like you can't do that. So I do think that some clinicians aren't built for it, for sure. It doesn't mean, like they may be, they're excellent CBTers. Oh my God, you need CBT. Great, they're great at it. But this, what you're talking about is a way of being with people. And I think that therapists need to be able to tolerate a lot of ambivalence. They need to tolerate, not tolerate, they need to be able to understand emotion dysregulation and not. react personally to it? Like, you know, right? And you can have limits, like you can communicate, like, yeah, I'm not going to call you back right now. Because remember we talked about that, right? Yeah, no, right? You know, but you can still be kind and hold limits. But I find people, especially when you're dealing with people that have eating disorders, or what we call personality disorders, I think that the level of emotion dysregulation, the level of interpersonal disregulates the therapist, who then intervenes in a way that actually makes the client worse, and then they go see the client. And I'm like, oh no, but it's an interaction. But this is what I mean, like if you're in DBT and you're not getting phone coaching, you're not in DBT. If you're getting DBT from one solo practitioner, you're not in DBT. Sean (01:24:54.305) Yes. Yep. And, you know, if the practitioner is responding after every time a person cuts or is not following the principles of the treatment, you're not getting DBT either. And so, yeah, if there is no pretreatment and that isn't explained and they don't understand it, so when the time comes and you say 24-hour rule, they see it as being punished, well, there was no agreement. You know, they never got to that point in the first place. Anita Federici (she/her) (01:24:55.981) You know? Anita Federici (she/her) (01:25:18.164) Roger. I just did. I'm finishing up a training with a large eating disorder day treatment and inpatient program here in Canada. And we did a whole, a couple of days just on contingency management. And I, one of the things that I emphasize with them is that, you know, first of all, you cannot do contingency management. You can't have limits. You can't do that. So if you haven't, there's no commitment to it. You haven't explained it. And the client doesn't go. Oh shit, I get why you would do that. I don't like it, but I kinda do it. And you collaborate with them. Okay, let's try to set limits together. So the one psychiatrist, she looked at me and she says, so this is so interesting, she said, because we tell them that we're gonna have limits, but we don't tell them why. I said, but that, right? Sean (01:26:11.877) Yeah, the one other piece that we don't talk enough is how DBT actually talks about the mental health system, the greater system as creating contingencies, where when the person is doing worse, they get the best, most attention, most care. And so until you flip that, right? You know, let's say, you know, you're getting some really good help, and then you start getting better. Anita Federici (she/her) (01:26:26.478) Yeah. Sean (01:26:41.469) Well, then you could, then you're done, right? Then you, then you might be out of the, out of the therapy. You might lose some supports, things that were really important to you. So like, let's say we change that. Let's say, you know, we created a stage three treatment that was all around, even when a person's stable and doing really well, they don't know they're not in their eating disorder anymore and they're, and you have this stage three treatment around just creating a life worth living. And then you also kind of like, Anita Federici (she/her) (01:26:47.596) Yeah. Yeah, that's huge. Anita Federici (she/her) (01:26:55.408) Mm-hmm. I love it. I wish. Sean (01:27:07.425) taper off the therapy in a certain way. They can have boosters when they want to come back for just a little sessions. They don't feel like they're just kicked out not getting it again. You know, we have to look at how we respond to when someone struggling. And you know, that's why you have to be so regulated and skilled as a therapist. Because if you do get lashed out at in a session, which we do, which you do. Anita Federici (she/her) (01:27:17.849) in. Anita Federici (she/her) (01:27:29.364) And you will. Yeah. Sean (01:27:32.397) You have to be very mindful of how you react. Are you completely different now? And they just got something from that and it stopped you from going in places that were really important in the therapy or you changed the way you reacted to them. Now they learn that when I act like this, I get to, my environment changes for the betterment of me. You know, all those things are important and you have to kind of be so radically genuine and you have to be so comfortable in that discomfort. Anita Federici (she/her) (01:27:36.597) Yeah. Anita Federici (she/her) (01:27:47.001) Yeah. Anita Federici (she/her) (01:27:51.14) Yeah. Anita Federici (she/her) (01:27:57.657) Thank you. Sean (01:28:01.317) And people who have been invalidating environments, they trust the openness, and they can see through bullshit. They know when someone is giving you some fake sympathy, you know, when they're trying to just provide the standard therapy speak junk. When you have somebody in there who's going to be just themselves and say, Hey, this is what I can do. This is what I can't do. This is what you can get from me. This is why you're going to get it from me. And listen, I can I care about you. And I don't like the way you're, you know, you're talking to me right now. You know, all these things are just Anita Federici (she/her) (01:28:01.72) and Sean (01:28:30.885) a different reaction by how standard mental health treatment, how they're trained to be. And people don't get it. People don't understand it. And it certainly can be misrepresented. Because I think for most clinicians, that would seem not professional. Like they think they're supposed to act a certain way. But when you talk to somebody in the way that you're communicating is like, hey, listen, you know, I'm a human being too. Don't attack me. Let's work on this together. Like there's a human moment there that maybe you feel a little more connected to. Anita Federici (she/her) (01:28:47.632) There's that. Anita Federici (she/her) (01:28:52.203) Yeah. Anita Federici (she/her) (01:28:59.832) Some of it, like in the eating disorder side of things, what I would say is that a lot of clinicians will tell me that they're just uncomfortable and with any sort of self-disclosure. So even though it's self-involving self-disclosure and it's a DBT strategy, they see that as a boundary. Like they're not used to that, so it's uncomfortable. Others are conflict avoidant in lots of areas in their life. And so when the client is upset, Sean (01:29:00.481) That was a question. Anita Federici (she/her) (01:29:25.888) you know, they tend to want to soothe the client, which may or may not be the helpful strategy, or they want to soothe themselves. So they do what they can to soothe the moment so they don't have to tolerate it. A lot of them are afraid that if they set a limit, their client will try to kill themselves, so better not set limits. This is really significant in eating disorders, where people are medically unstable. If I hold a limit, then they're not in the treatment anymore and they could die. Like there's all this kind of stuff that goes on. Yeah, I think there's a lot of work for the therapist to really, and this is why you need a team. This is why I don't believe you can work with really complicated human beings with complex needs and not have a team. Like if I was by myself, even with all that I know and feel confident in, I don't think I would be a very great... therapist because I drift. I drift, I'm human, you're going to affect me and I'm gonna affect you and my team is the one that goes, hey Anita, I'm just noticing. You're actually treating this person differently than you treat other people and I'm like, shit, I am. What's that about? So if I don't have a team, none of that gets to happen. Right? Sean (01:30:41.245) Yeah, great points. I mean, and that is the value of our consultation team. And, you know, we have such a strong consultation team here, you know, we can we can walk in that and say, you know, I really fucked up here. You know, I just wasn't, I wasn't at my best. And I wish I would have done that. And then you can you just explore what led you to do the things that you did and then how to repair. I mean, that's the great thing about Anita Federici (she/her) (01:30:53.968) Yeah, I love that. Anita Federici (she/her) (01:31:00.631) Yeah. Sean (01:31:10.197) DBT is, you know, you are a human, you might be the therapist, your psychologist, but you're not perfect in some areas that they struggle with you struggle with. And so that openness and that self disclosure is important. And sometimes just saying, Hey, you know, I screwed up, I'm sorry. I mean, this is what my intention was, it didn't, I didn't do a great job of communicating it or coming across, I fell short here for you. But I think we can we can learn from it together. And it's a different approach to life and not always what they got in relationships or with their family growing up. Anita Federici (she/her) (01:31:27.223) Yeah. Sean (01:31:38.441) Yeah, you got to put your ego to the side in order to do that. Oh, yeah, there's no ego. Yeah, that's all going to be put aside. Anita Federici (she/her) (01:31:41.792) Yeah, no, but that notion of equality, again, that is what you're talking about isn't typical in most eating disorder frontline treatments. So even if I take it like, yes, there's DBT, but then there's the whole side of what does it mean for people with eating disorders? And it's why I, that's all I do now is MedDBT because it's so collaborative and compassionate. Even when it's not working, like I'm very clear with people like this may or may not work I still don't have the treatment for everybody at every moment I don't I wish I did but I don't But I'm gonna be I'm gonna be transparent with you But what I think is happening and I want you to be transparent with me so we can co-create together Using theories and using the target hierarchy and but we got to agree on that stuff And if I and if it's not working, then I'm gonna stop and maybe this isn't like maybe it's not But again, I have more successes in using med than I do with anything else. You know, and I even do like a med DBT family group once in a while, sometimes I offer it, sometimes I don't, just depends on demand. And even the parents, and it could be parents of adult clients, like it's just, you know, friends and family. And I go through, I have an adapted biosocial theory, right? I have like, so, you know, where does, how does the eating sort of fit in the bio and the social and so on and so forth. The most common response I get from people is, why didn't someone just explain this to me earlier? Why wasn't this part of the treatment five years ago? Why is this the first time I'm hearing about this? And I tell them like, that's a really good question. You know? Sean (01:33:26.473) Yeah, the one thing I want to just close on is, um, you know, how important it is to be upfront with people about what therapy actually is and what therapy isn't, you know, the one thing I've certainly learned throughout my experience in this field is just coming to talk to me in itself is not therapeutic, just a talk therapy is not going to get you out of an eating disorder. I mean, it's probably not going to significantly change some real problem behaviors and ways of relating that exist. You might get some insights, you might get some support, but ultimately, I think that's going to fall short. When you take a when you take an approach, that we have to think about therapy as something that's, you know, that's daily, right? If I wanted to change my health, if I wanted to go to the gym, I can't do it once a week. I can't just eat well once a week. for an hour and hope that transforms something. And sometimes that's how it's communicated in a mental health field. Like some magic occurs in a talk therapy. It's not necessarily the case. I mean, motivation can be built there, support, learning new things certainly can occur, but it's that application back into their lives and changing the way that they cope or the patterns that exist, like altering them in new ways to get better results, right? Anita Federici (she/her) (01:34:29.613) Yeah. Sean (01:34:44.145) And that is, and that's hard work, especially in the beginning can provoke a lot of fear. It is, it's something that can, um, you know, create just a sense of like unbalance and discomfort. Sometimes it can be like an, even an increase of some problem reactions in the beginning. But it's that you do have to be upfront. It's hard work. Really, really hard work, you know, coming to this skills training that we have here, Sean, you know, it's the homework then that they take back into their day to day life. Anita Federici (she/her) (01:34:48.609) Mm-hmm. Anita Federici (she/her) (01:35:00.01) Mm-hmm. Anita Federici (she/her) (01:35:06.726) Yeah. Sean (01:35:14.149) Um, it's, it's the self monitoring, you know, with that diary card, it's the willingness to reach out in a difficult moment. It's a seven day, 24 hours a day, you know, work here. And I'm not going to give you a line of bullshit and just think that you can come in here and do what you've always done and expect the same results because that's insanity, but I'm going to work with you. You know, I'm going to be right there with you and I know what it takes. I've seen it. Anita Federici (she/her) (01:35:19.038) Mm-hmm. Anita Federici (she/her) (01:35:25.915) Love that. Sean (01:35:43.261) I've seen it from people. I've got the playbook, you know, following the playbooks hard. I'm not saying it's easy and the guarantee we're going to fail. We're going to fall down, you know, but we're gonna have to be able to get back up and learn from it and you'll be so much better at this point, but you gotta be willing and you know, so that's that willingness to be able to engage and to just show people that there's, there's no magic switch that takes place. I mean, this is hard work. Anita Federici (she/her) (01:35:44.749) Yeah. Anita Federici (she/her) (01:36:04.972) Yeah. No. Anita Federici (she/her) (01:36:10.168) You know, you're, I'll just, one thing you're reminding me of is Charlie Swenson, who is a, you know, internationally known DBT author. And, you know, I, and he has some, you know, he says, you know, it's like the person is in jail, right? And he says, you know, do you want me to come every week and visit you in jail and bring you a cake and we'll talk and then I'll go home and then I'll come back. Or do you want me to break you the hell out of jail? Like, what are we doing? Sean (01:36:36.501) Yeah, I love it. Anita Federici (she/her) (01:36:38.208) Like, am I visiting you and just checking in? Because people will do that for you. People will do that for years with you. Or are we trying to break out? And I love that. And I think that's what people like you and I are doing. Sean (01:36:47.617) That's great. Sean (01:36:52.377) love it. That's a that's great to end on. Right there. I mean, we've touched on so many different subjects. And really, I'm grateful for Anita for taking the time to have this conversation. Where can our listeners find you or your work? What's the easiest way to access what you're doing? Anita Federici (she/her) (01:36:59.184) I'm going to go ahead and close the video. Anita Federici (she/her) (01:37:12.152) Yeah, probably on. I try to keep the most current stuff on Instagram, Dr. Anita Federici. Anything else that I do would be linked to that. And just like a deep, sincere thank you. It was really enjoyable to talk with you both. And it's just an honor to be able to share ideas with like-minded people. So thank you very much. Sean (01:37:35.346) Dr. Anita Federici, we want to thank you for a radically genuine conversation.