219. What Every Doctor Should Know

What if we spent less time trying to get rid of eating disorder symptoms and more time understanding why they're there in the first place? In this episode, I'm joined by Nancy McWilliams, psychologist, psychoanalyst, and author with more than 50 years of experience in psychotherapy. I've been reading her work for over a decade, so getting to have this conversation was a pretty big deal for me. We talk about what eating disorders might be doing for someone emotionally, why food can become a way to manage feelings we don't know how to name, and how early relationships can shape the way we experience food, control, and connection. We also get into why simply identifying a feeling doesn't magically make it go away. Wouldn't that be convenient? Quotes "We have a lot of research now that shows how much patients want self-understanding, not just symptom reduction. And sometimes when you're successful at reducing symptoms, the patient gets under stress, and they don't know what to do, and they get the symptom back." - Nancy McWilliams "What matters to the patient is not the brand name of the therapy; it's the quality of the relationship." - Nancy McWilliams "If you're able to just help a person speak their truth, you're doing something positive for them. Maybe they won't be able to conquer their eating disorder this year. Maybe they'll have to bottom out in some way and come back in a couple of years, but they'll remember that you were kind and compassionate and that you weren't judgmental." - Nancy McWilliams "I think every time you make a genuine connection with another person, even if they couldn't use you at that time to move forward toward better mental health, it matters to them." - Nancy McWilliams "People are always on their phones, even if they're sitting around the same table. They're not actually eating together." - Rachelle Heinemann Frequently Asked Questions 1. What is psychodynamic therapy for eating disorders? It's a way of working that looks at what's underneath the eating behaviors, like the emotions, relationships, and past experiences that might be driving them. Nancy explains that most people come to therapy wanting to understand themselves, not just reduce a symptom. The relationship with the therapist is a big part of the work.   2. Is focusing on eating disorder symptoms enough? Sometimes it has to come first. Nancy is clear that if someone is in bad health, you work on getting them to eat. She also points out that when symptoms are reduced without understanding what's behind them, they can come back under stress. Her take is that both matter.   3. Why do people develop eating disorders? It's different for everyone. Nancy shares examples like eating to feel soothed when a home wasn't comforting, chasing thinness because of what the culture rewards, eating when angry or sad, and using food to feel in control when everything else feels out of control. Early experiences with feeding and family meals can also shape our relationship with food.   4. Is an eating disorder an addiction? Nancy says parts of eating disorders look a lot like addictions, and similar brain processes get activated. She explains that psychoanalysts learned decades ago that with addictions, understanding yourself isn't enough on its own. You have to focus on the behavior directly too.   5. Why do I use food to cope with my emotions? When we weren't given words for intense feelings, we often don't know what we're feeling. We just feel activated. Food can quiet that, whether it's anger you don't recognize as anger, anxiety, or sadness you don't know how to grieve. Nancy shares a client who felt enraged after being criticized at the dinner table but only knew she felt terrible, and eating was what made her feel safe.   6. Why can't I name what I'm feeling? Is "overwhelmed" a feeling? According to Nancy, overwhelmed isn't a feeling; it's what we say when we don't have words for one. Feelings sound like angry, sad, disappointed, resentful, or envious. She mentions a therapy program where adolescents were asked to name five feelings a day, and she describes the approach as helping enormously.   7. What makes therapy work for eating disorders? Nancy points to the relationship, not the brand of therapy. Studies keep finding that therapist qualities like warmth, genuineness, hope, and compassion matter most. Trust takes time to build, especially for someone starting at zero, and that's okay. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!  Related Episodes Episode 126. Lying, Deception, and Eating Disorders with Tom Wooldridge, PsyD, ABPP, FIPA, CEDS-S Episode 171. Healing the Hidden Wounds of Disordered Eating with Dr. Katheryn Zerbe  Episode 107. The Rules of the Therapy Game with Dr. Dana Satir, CEDS Episode 82. Secrets and Eating Disorders with Dr. Kathryn Zerbe Episode 64. When Words Fail and Bodies Speak with Tom Wooldridge PsyD, ABPP, FIPA, CEDS-S Episode 26. Eating Disorders and the Mind/Body Disconnect with Danielle Novack, Ph.D   Thank you to our sponsor! This episode includes paid endorsements and advertisements for products and services. Therapists, listen up! What if the right EHR could transform the way you run your practice and meet needs you didn't even know you had? With TherapyNotes, managing your practice gets a whole lot easier. It brings the tools you need together in one place, from customizable note templates and electronic claims to an integrated client portal and more. And with TherapyFuel, their assistive AI suite, you can streamline time-consuming tasks with features for progress notes, session refreshers, and more, so you can spend less time catching up and more time focused on your clients. Plus, TherapyNotes Mobile brings the features you know and love right to your mobile device, so your practice can keep moving wherever your day takes you. Unlimited support, smart features, and flexibility on the go. Now that's practice management. Use code UDE to get your first two months of TherapyNotes FREE. Please note, this promotion is only valid for brand new TherapyNotes customers.  Sign up now! https://bit.ly/3Vyypvl Promo Code: UDE   LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

There are certain things you assume medical professionals just know. Like how to read labs, how to diagnose things, or how to tell you what's going on with your body. But when it comes to eating, weight, and our relationship with food? There's a lot more nuance than "you should probably lose some weight" and a BMI chart. In this episode, I'm talking about what I wish every medical practitioner understood about working with patients around food and weight. We're getting into why asking questions before giving advice matters, why your patient probably already knows what they're "supposed" to be doing, why weight advice can create shame instead of change, and why the way you deliver information can matter just as much as the information itself. Quotes "We need to ask questions, because we have no idea how someone feels about their weight."  "The BMI chart tells you the average. It doesn't necessarily indicate health."  "I'm saying we have to be a lot more deliberate. We have to be a lot more understanding and curious, understanding the limits of our training, understanding the limits of our relationship."  "The sentiment here is: ask before you advise, because you have no idea what you're working with before you tell them to do something." "Just saying to change how you eat or how you move is so invalidating, and it alienates them, and at the end of the day, it really keeps them from helping themselves. This is more of a question of what stops them from implementing things that they already know to do."  "Our words matter. And the choice of words matters even more. Some people might hear it as criticism." "It can really make or break a person and their relationship with food and their relationship with themselves when we have a critical tone." "I can't tell you how many times people say, 'I went to the doctor and this thing stuck in my head and I cannot stop thinking about it.'" Frequently Asked Questions 1. What is weight-neutral healthcare? Weight-neutral healthcare focuses on a person's overall health, behaviors, symptoms, blood work, and other health indicators rather than assuming that weight itself is the primary problem that needs to be changed.   2. Does BMI actually indicate health? BMI can provide information about where someone falls compared with population averages, but it does not tell you everything about an individual's health. Two people with the same BMI can have very different relationships with food, activity levels, symptoms, and overall health.    3. Why can weight-loss advice be harmful? Weight-loss advice can create shame rather than meaningful change, particularly when a practitioner doesn't understand the person's existing relationship with food, movement, or their own body. Shame can also make people less likely to open up or return for care.   4. How should doctors talk to patients about weight? Doctors and other medical practitioners should ask questions before making assumptions or giving advice. Understanding how someone feels about their weight, their relationship with food, their movement habits, and what they've already tried can lead to a much more appropriate conversation.    5. What is the difference between a weight-neutral dietitian and a weight-loss dietitian? A weight-neutral dietitian focuses on developing an approach that considers the individual's relationship with food, health, and behaviors rather than automatically centering weight loss. For someone with a chaotic relationship with food, the episode recommends looking for an eating disorder dietitian, intuitive eating dietitian, or weight-neutral provider.    6. Why is it important to ask questions before giving health advice? Patients may already be doing many of the things a practitioner is about to recommend. Without asking questions first, a practitioner may give advice that is inaccurate, unnecessary, or potentially harmful to someone who already has a rigid or obsessive relationship with food or exercise.   7. Can a doctor's words affect someone's relationship with food and their body? Yes. The episode emphasizes that medical practitioners have significant influence over how patients think about themselves. Even comments that aren't intended as criticism can stick with someone and affect their thoughts about their body, food, and health long after the appointment. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!  Related Episodes Episode 188. How to Recover in a Weight Loss and GLP-1 Obsessed World Episode 149. Why Your Doctor Doesn't Need to Weigh You with Dr. Mara Gordon Episode 133. GLP with Dr. Kim Dennis Episode 130. So You Think Processed Foods Caused Obesity and the Answer is Weight Loss Thank you to our sponsor! This episode includes paid endorsements and advertisements for products and services. Therapists, listen up! What if the right EHR could transform the way you run your practice and meet needs you didn't even know you had? With TherapyNotes, managing your practice gets a whole lot easier. It brings the tools you need together in one place, from customizable note templates and electronic claims to an integrated client portal and more. And with TherapyFuel, their assistive AI suite, you can streamline time-consuming tasks with features for progress notes, session refreshers, and more, so you can spend less time catching up and more time focused on your clients. Plus, TherapyNotes Mobile brings the features you know and love right to your mobile device, so your practice can keep moving wherever your day takes you. Unlimited support, smart features, and flexibility on the go. Now that's practice management. Use code UDE to get your first two months of TherapyNotes FREE. Please note, this promotion is only valid for brand new TherapyNotes customers.  Sign up now! https://bit.ly/3Vyypvl Promo Code: UDE LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

This episode is for you if that sounds familiar. If you love someone in recovery or sit with people in recovery every day, stay close, because there's a lot here she might not be telling you. A lot of recovery content swaps diets and clean eating for a new standard to measure yourself against. The comparison stays exactly the same: she's doing it right and I'm not. High achievers get hit hardest, since a model of the good way to recover is basically an invitation to ace it. Quotes "Nobody posts the meal that was kind of boring and just fine. That's what it looks like when food stops being the main character." "What you're doing then is comparing your unedited inside to someone else's selected outside." "I think the best question for us to ask is, "Do I feel less alone right now or do I feel behind?"" "Most recovery happens offline, like in private, in moments that, if we're being real here, are too small and sometimes almost too strange to post." Frequently Asked Questions Why do I feel worse about my recovery after scrolling social media? Recovery content often swaps diet culture for a new standard to measure yourself against. The content is different, but the comparison is the same: she's doing it right and I'm not. Feeling behind after a scroll doesn't mean you're failing. It points to a part of you that is still looking for someone to tell you you're doing it right.   Is recovery content on social media helpful or harmful? It can be both. Seeing someone else go through meals, appointments, and food challenges can feel validating and make you feel less alone. It becomes unhelpful when you start measuring your plate or your timeline against theirs.   What is the difference between feeling understood and comparing yourself to others in recovery? Feeling understood happens around feelings like fear, ambivalence, and joy. Comparison starts when you look at what's on someone's plate or how far along they are. The first leaves you less alone. The second leaves you feeling behind.   Why do I feel behind in eating disorder recovery? Feeling behind usually comes from "shoulds" such as "I should be eating ice cream by now" or "I shouldn't need more support." Social media may give those thoughts a face, but they usually start with what you believe recovery is supposed to look like and who you think you have to be to deserve it. A therapist or dietitian can help you work through them.   Is it normal to compare my recovery to someone else's? Yes, and high achievers tend to feel it hardest. If you're handed a model of the "good" way to recover, you'll try to ace it. Social media also shows an edited, chosen version of someone's recovery, so you end up comparing your unedited inside to their selected outside.   What does eating disorder recovery actually look like day to day? Mostly it's small and hard to film. It's the random Tuesday you ate lunch and didn't think about it, the fight where you said the thing instead of skipping a meal, or the moment you let yourself want something. You may not notice it in the moment, which is what it looks like when food stops being the main character.   How can clinicians and family members support someone who compares herself to recovery content online? Get curious about what she is measuring herself against rather than telling her to unfollow. Listen for the "shoulds," and notice whether she is trying to be the good recovery story in the room by performing progress. The goal is a space where she can be seen, which social media can't offer. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!  Related Episodes Episode 173. Being Present and Eating Disorders Episode 172. Imposter Syndrome and Eating Disorders Episode 147. Social Media and Eating Disorders with Lily Thrope, LCSW Episode 146. Caring Less About What Others Think   Thank you to our sponsor! This episode includes paid endorsements and advertisements for products and services. Therapists, listen up! What if the right EHR could transform the way you run your practice and meet needs you didn't even know you had? With TherapyNotes, managing your practice gets a whole lot easier. It brings the tools you need together in one place, from customizable note templates and electronic claims to an integrated client portal and more. And with TherapyFuel, their assistive AI suite, you can streamline time-consuming tasks with features for progress notes, session refreshers, and more, so you can spend less time catching up and more time focused on your clients. Plus, TherapyNotes Mobile brings the features you know and love right to your mobile device, so your practice can keep moving wherever your day takes you. Unlimited support, smart features, and flexibility on the go. Now that's practice management. Use code UDE to get your first two months of TherapyNotes FREE. Please note, this promotion is only valid for brand new TherapyNotes customers.  Sign up now! https://bit.ly/3Vyypvl Promo Code: UDE  LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

In this episode, I'm digging into what might be underneath that "you just don't get it" reaction, from body image and fear of failure to grief, control, and the feeling that someone else is trying to make decisions about your body. Because sometimes, the eating behaviors we're trying so hard to change are serving a purpose we haven't fully understood yet. I'm also talking to clinicians about what to do when a client pushes back against advice that's technically correct. Spoiler: labeling someone noncompliant and moving on probably isn't going to get you very far. Quotes "You can't be talked out of doing something that's doing a job." "Having a reaction to something, whether it's rolling your eyes or writing it off or shutting down, doesn't mean that it makes it incorrect. It just means you're having a reaction and we can try to understand what it is." "Whether it's a plan you're not ready to see fail, the loss you haven't let yourself feel, the one place that you get to steer, or the last thing that's still yours to decide, the way that you eat is holding something for you, which is why a "lecture" bounces off." "And as long as it's still ahead of you, it's still possible. Anything is possible. You're full of hope." "Even when the advice is completely correct, doing it on someone else's timeline can really feel like losing the last thing that was yours to decide" "It's not just about delivering the information; it's understanding how the person is receiving it." "Don't argue with the advice, and don't just swallow it. Ask what just happened internally when you heard that sentence. Ask what it might be protecting." Frequently Asked Questions Why is it so hard to eat more when you have an eating disorder? Knowing that you need to eat more doesn't automatically make it easier to do. Fear of weight gain, body image concerns, and anxiety about changing familiar eating patterns can make eating more consistently feel overwhelming.   Why do I feel guilty after eating? Guilt after eating can be connected to food rules, body image concerns, fear of weight gain, or beliefs about what and how much you should eat. Exploring what those feelings mean to you can help you better understand your relationship with food.   How can I eat more consistently with an eating disorder? Eating more consistently often involves understanding what makes regular eating difficult, including fears around food, body image, and weight changes. Working with an eating disorder-informed clinician or dietitian can help you develop a plan that supports your nutritional needs and recovery.   How does body image affect eating disorder recovery? Body image concerns can make recovery challenging when eating more consistently feels connected to giving up a hoped-for body size or weight. Working through those fears and the grief associated with changing body expectations can be an important part of recovery.   Why do I resist advice even when I know it's right? Resistance can happen when advice feels threatening to something important, such as a sense of control, hope, independence, or ownership over your body. Understanding what your reaction might be protecting can help you explore the resistance instead of simply fighting against it.   What is the difference between restrictive eating and emotional eating? Restrictive eating involves limiting food intake, while emotional eating generally refers to eating in response to emotions. These experiences can overlap with other eating patterns, and neither label alone tells the whole story of someone's relationship with food or nutritional needs.   How can therapists help clients who resist eating disorder treatment? Therapists can explore a client's reaction with curiosity rather than immediately labeling it as noncompliance or avoiding the conversation. Asking what happened when the advice was offered, what felt difficult about it, and what the reaction might be protecting can help uncover barriers to recovery. Resources Sign up for my upcoming webinar: Foundations of Eating Disorder Treatment Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here!  Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    Related Episodes Episode 191. Why You Can Be Doing Everything Right and Still Feel Worse Episode 146. Caring Less About What Others Think Episode 120. Disordered Eating VS Eating Disorder, Which Is It? Episode 111. How To Eat When You Don't Feel Like It   Thank you to our sponsor! This episode includes paid endorsements and advertisements for products and services.  Therapists, listen up! What if the right EHR could transform the way you run your practice and meet needs you didn't even know you had? With TherapyNotes, managing your practice gets a whole lot easier. It brings the tools you need together in one place, from customizable note templates and electronic claims to an integrated client portal and more.  And with TherapyFuel, their assistive AI suite, you can streamline time-consuming tasks with features for progress notes, session refreshers, and more, so you can spend less time catching up and more time focused on your clients. Plus, TherapyNotes Mobile brings the features you know and love right to your mobile device, so your practice can keep moving wherever your day takes you. Unlimited support, smart features, and flexibility on the go. Now that's practice management. Use code UDE to get your first two months of TherapyNotes FREE. Please note, this promotion is only valid for brand new TherapyNotes customers.  Sign up now! https://bit.ly/3Vyypvl Promo Code: UDE PS: I'm teaching Foundations of Eating Disorder Treatment in 60 Minutes on Thursday Oct 22 at 1pm ET on Zoom. If eating disorder cases keep landing on your caseload without training, this hour is for you. $49 individual, $129 for a whole practice, recording included. Details and registration. LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

That feeling of I'm not enough can show up in a lot of ways. In this episode, we're getting curious about what not feeling enough is actually telling you. Sometimes what you're jealous of isn't really the person, their body, their career, or their life. It might be the ease, confidence, connection, pride, or freedom you think they have.  And when we don't stop to figure that out, those feelings can get redirected into something else. For some people, that might mean restriction, bingeing, purging, compulsive exercise, or constantly promising that tomorrow will be the day they finally get it together. Quotes "One passing thought or even a variety of passing thoughts isn't a verdict on you." "This is like an urgency to it, and it's sort of like an urgency with this energy that has nowhere to go." "Jealousy or comparing or noticing something that you lack, that's all information in the direction that you would like to go, whether it's conscious or not." "A lot of people pursue restriction in the effort to feel like they have been good or good enough for the day." "In some senses, purging, fasting, exercise is a way to get rid of the feeling like I'm too much, which ironically is kind of the same thing as not feeling enough." "The promise to be better and then not following up on it is just sort of another manifestation of chronic insecurity, not feeling good enough." "The biggest question is what it's actually costing you and whether that cost matches what you say you want." "Once you name it, you'll notice it's not really about that other person, it's not really about you, and it's not even about not being enough. It's about the thing that you don't have." "I think that there is a lot of utility in being curious about what is the area in particular that I don't feel good enough, that I feel insecure, because that lets us know where we can actually make movement as opposed to just staying with affirmations stuck to our mirror that might not resonate." Frequently Asked Questions 1. Why do I always feel like I'm not good enough? Feeling "not good enough" can show up when you compare yourself to other people, a previous version of yourself, or the expectations you have for your life. The important question is what specifically feels lacking. Getting curious about that can help you identify what you actually want or need instead of simply criticizing yourself.   2. How does low self-esteem affect eating disorders? Low self-esteem and feelings of inadequacy can become connected with eating disorder behaviors. The episode explores how the urge to feel "good enough" can sometimes get redirected into restriction, bingeing, purging, fasting, or compulsive exercise. These behaviors may provide temporary relief from difficult feelings without addressing what is underneath them.   3. Why do I compare myself to other people? Comparison can sometimes point to something you want or feel you are missing. Instead of stopping at "I wish I were like her," the episode encourages getting specific about what you are actually noticing, such as ease, confidence, connection, pride, or more room to breathe.   4. Can feeling insecure lead to disordered eating? It can be one way difficult feelings get redirected into eating disorder behaviors. The episode discusses how restriction, bingeing, purging, fasting, and compulsive exercise can sometimes function as ways to manage or escape feelings of insecurity, inadequacy, or being "too much."   5. Why do I feel like I need to change my body to feel good enough? Sometimes the desire to change your body becomes tied to a deeper belief that reaching a certain size, weight, or appearance will finally make you feel good enough. The episode challenges that connection by asking what you are actually hoping to gain from the change and what pursuing it may be costing you.   6. Is wanting to improve myself a bad thing? No. The episode makes an important distinction between wanting something different for yourself and becoming consumed by the belief that you have to change in order to be enough. Wanting to improve can provide useful information. The bigger question is whether the cost of pursuing that goal matches what you actually want from your life.   7. How can I stop feeling like I'm not enough? Rather than immediately trying to silence the thought, start by getting specific. Ask yourself what you believe another person, an earlier version of yourself, or an "ideal" version of you has that you want. It might be ease, connection, confidence, pride, trust, or something else. Once you identify it, you can begin thinking about how to build that thing in your own life.  Resources Sign up for my upcoming webinar: Foundations of Eating Disorder Treatment Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    Related Episodes Episode 211: The 2 Fears Running Your Eating Disorder (And Why They Contradict Each Other) Episode 198: People Pleasing and Eating Disorders Episode 105: The Root of Your Emotional Eating Episode 11:  Utilizing Curiosity to Develop Resilience and Eliminate Harmful Comparison with Jennifer Glass, LCSW   LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

When you hear the word bulimia, you probably have a picture in your head. And that picture can make it harder to recognize what's actually happening. We tend to have this very specific idea of what bulimia looks like, who has it, what purging means, and how serious someone has to be before their struggle "counts." Which is a problem, because a lot of people with bulimia don't look anything like the picture we've been given. In this episode, I'm getting into the parts of bulimia that are easier to miss. The purging behaviors that don't involve vomiting. The restriction that often gets overlooked. The shame that keeps people from telling the truth about what's happening. The dissociation that can happen during a binge. And the very real medical risks that can exist even when someone looks completely fine on the outside. Quotes "At a certain point it doesn't really matter what the name of the diagnosis is. If somebody is suffering from an eating disorder, whether it's called bulimia or other specified or whatever else they might be called still an eating disorder and still just serious enough to require treatment." "We as a treatment team community need to know when to ask more questions, when to be soft, when to push a little harder, and when to make space to be able to talk about shame." "Purging doesn't only mean self-induced vomiting." "The body can be carrying real acute risk while looking completely fine on the outside. It's not that it doesn't exist; it's just that it's sort of invisible to the naked eye." "There's this other less-paid-attention part of the issue, which is the restriction because the restriction is actually something that they like, so that's not really a problem." "One of the biggest pieces of bulimia is shame, and when we feel ashamed, we're not talking about it. So if there is any environment ever that can be created for this person to be able to identify feelings of shame and talk a little bit more explicitly with detail and honesty about what they're struggling with, that in and of itself is the treatment." "You don't have to check boxes in order to have suffering count as real." Frequently Asked Questions 1. Can you have bulimia if you are not underweight? Yes. People with bulimia can be in average-weight or higher-weight bodies. Body size alone cannot determine whether someone has bulimia.   2. What counts as purging in bulimia? Purging can include self-induced vomiting, laxative misuse, diuretics, enemas, fasting, and compulsive or excessive exercise used to compensate for eating.   3. Can excessive exercise be a form of purging? Yes. Exercise can function as a compensatory behavior when someone is using it to compensate for eating, such as feeling that they need to exercise because they ate a particular food or amount.   4. Is bulimia dangerous even if someone looks healthy? Yes. Bulimia can involve serious medical complications, including electrolyte imbalances and heart complications. Someone can look physically fine while still experiencing significant medical risk.   5. Why do people with bulimia hide their symptoms? Shame can make it extremely difficult to talk honestly about bingeing, purging, and other eating disorder behaviors. Some people may also minimize their symptoms because they don't believe their experience is serious enough to "count."   6. What is the relationship between restriction and bulimia? Restriction can be an important part of the binge-purge cycle. Someone may have significant food rules, limit their intake, cut out foods or food groups, or simply not eat enough, which can contribute to bingeing and subsequent purging.   7. Can you have an eating disorder without meeting the criteria for bulimia? Yes. The episode emphasizes that someone can have significant eating disorder behaviors and suffering without meeting every criterion for a specific diagnosis. The exact diagnosis does not determine whether someone's suffering is legitimate or whether they deserve treatment. Resources Sign up for my upcoming webinar: Foundations of Eating Disorder Treatment Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

In this episode, Heather Ferguson is back, and we're taking that conversation a whole lot deeper. We're talking about what happens when we slow down enough to pay attention to what's happening in the body, how trauma can show up when someone doesn't have the words to explain what they're experiencing, and why recognizing the connection between trauma and an eating disorder doesn't automatically tell us how to support someone through healing.  Heather Ferguson, LCSW, is a psychoanalyst, faculty member, and supervisor at the Institute for the Psychoanalytic Study of Subjectivity and the National Institute for the Psychotherapies. As a certified hypnotherapist and EMDR practitioner, she incorporates embodied techniques into her psychoanalytic work. She writes about eating disorder treatment, the role of intergenerational trauma transmission, and how embodied techniques can deepen psychotherapeutic engagement. Heather is co-editing a forthcoming book with Susan Klebanoff entitled Revisiting Ferenczi's Unwelcome Child in Turbulent Times. She maintains a private practice in New York City. There's a lot packed into this conversation, and honestly, I could have kept asking questions for another hour. So grab your headphones and listen to the full episode. Quotes "So many of our patients are in that hypoarousal, more dissociated, collapsed state with disordered eating, particularly those that are really disordered and are maybe underfed, that their sort of neocortex is not online, that their thinking brain is not fed enough, and they are kind of shut down." - Heather Ferguson "I think helping patients learn the sequence of what happens; An emotion, a feeling state, a sensation and maybe their own protective defenses that may be the shutdown neurobiologists talk about the dorsal response, the collapse." - Heather Ferguson  "And I should say that I also use my body as information." - Heather Ferguson "We have mirror neurons, right? We map empathically, and we often imagine and feel with our patients." - Heather Ferguson "EMDR is not magical; it's just intense." - Heather Ferguson "And I think to sort of indicate how it's ingenious, how there's so much shame, and you know this." - Heather Ferguson "Let's not forget. We don't have to always fix it." - Heather Ferguson "Everyone doesn't walk around with equal freedom and safety in their bodies." - Heather Ferguson "There's two versions of the stuckness. There's the person who stays in this almost intellectual place of, 'This is the body that I want. This is the body that I don't have.' And there's no amount of work or talking about it that's going to change that. Then there's a different version of stuck. They've identified their associations with poor body image. They understand how their history connects here, and then they're like, 'Okay, we've talked about it.' And they're still stuck." - Rachelle Heinemann Frequently Asked Questions 1. Can trauma cause an eating disorder? Trauma can be a significant risk factor for developing an eating disorder, although there isn't always a simple cause-and-effect relationship. Trauma can influence emotions, body image, self-esteem, and coping, and eating disorder behaviors may become a way of managing experiences that feel overwhelming.   2. What is the connection between trauma and eating disorders? Trauma and eating disorders can become closely intertwined. Eating disorder behaviors may temporarily help someone numb, avoid, control, or cope with difficult thoughts and feelings. Over time, those behaviors can become part of the cycle that keeps both the distress and the eating disorder going.   3. Can an eating disorder be a coping mechanism? Yes. Eating disorder behaviors can serve a purpose for someone, even when those behaviors are harmful. Restriction, bingeing, purging, or other behaviors may provide temporary relief from anxiety, difficult emotions, shame, or a sense of being out of control. Understanding what a behavior is doing for someone can be an important part of treatment.   4. How does trauma affect body image? Trauma can affect the way someone experiences and relates to their body. For some people, body dissatisfaction, shame, or attempts to change or control their body can become connected to difficult experiences. Body image can also be influenced by lots of other factors like social expectations and other lived experiences.   5. What is trauma-informed eating disorder treatment? Trauma-informed treatment considers a person's history and the ways trauma may influence their thoughts, emotions, behaviors, and relationship with their body. It means creating space for that history without assuming every eating disorder has the same origin or that every client needs the exact same treatment approach.   6. Can you treat trauma and an eating disorder at the same time? Yes, trauma and eating disorders can be addressed through an integrated treatment approach. The timing and approach matter, especially when someone is actively struggling with eating disorder behaviors or is medically compromised. Treatment needs to be mindful not to do trauma work before they're ready.   7. Why is body awareness important in eating disorder recovery? Learning to notice sensations, emotions, and physical responses can help someone better understand what is happening internally and how that connects with their behaviors. For some people, this creates a bridge between intellectually knowing something and actually experiencing it in their body, which can be an important part of the therapeutic process. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

There are some questions that sound simple until you actually sit with them. This is one of those questions: "Can I work with a dietitian who specializes in eating disorders and also helps me lose weight?"  At first glance, it feels like a yes-or-no question. But underneath it is a much bigger conversation about recovery, autonomy, body image, health, medical advice, and the beliefs we've been taught about weight. In this episode, we're unpacking why this question is so complicated for both clients and providers, and why giving a quick answer often skips over the part that matters most. The real conversation usually isn't just about a referral. A question like this can come from many different places. Whether you're in recovery, supporting someone who is, or you're a clinician navigating these conversations, this episode will challenge the way you think about weight loss and eating disorder treatment. Quotes "Respecting the request and knowing what to do and what you end up choosing to do turns out to be two different things." "Questions always have something living underneath them." "The whole premise of eating disorder treatment is neutralizing your relationship with food." "When something feels intolerable... it says, 'I can't tolerate this feeling, so I need to manage it through food.'" "Neutralizing the relationship with food is almost impossible because there's always an outside agenda running every food choice." "There's a difference between someone whose health is genuinely at stake and somebody in real body image distress who just wants relief." "It isn't about getting it right or wrong. It's about opening up a conversation, opening up the exploration, and seeing what's there." "The referral is secondary. The conversation and the exploration is the primary." Frequently Asked Questions Can you lose weight during eating disorder recovery? There isn't a one-size-fits-all answer. The more important question is why weight loss feels necessary. In eating disorder treatment, providers often explore what's driving the desire to lose weight before discussing referrals or treatment options. The conversation behind the request is often more important than the request itself.   Should someone with an eating disorder work with a weight loss dietitian? It depends on the individual's situation, but the episode explains why this isn't a simple yes-or-no decision. Before making a referral, it's important to understand whether the request is rooted in medical concerns, body image distress, or something else entirely.   Why is weight loss complicated during eating disorder treatment? Eating disorder treatment focuses on building a more neutral relationship with food rather than making food choices based on weight goals. When weight loss becomes the primary focus, it can make it difficult to separate food choices from external rules and emotional distress.   Can you pursue health and eating disorder recovery at the same time? The episode discusses how health concerns deserve thoughtful exploration rather than blanket assumptions. Some people have legitimate medical questions, while others are primarily seeking relief from body image distress. Understanding which situation applies is an essential part of treatment.   Why do people want to lose weight during eating disorder recovery? For some, the desire comes from concerns about physical health. For others, it's an attempt to escape the emotional pain of body image distress. Although the request may sound the same, the reasons behind it can be very different and deserve careful exploration.   What is the goal of eating disorder treatment? The goal is to develop a healthier, more neutral relationship with food by reducing reliance on rigid food rules and learning to make decisions based on internal needs rather than external pressures. This creates space for healing instead of continuing the cycle of using food to manage emotional distress.   What should therapists do when a client asks for weight loss during recovery? Instead of immediately saying yes or no, therapists can use the request as an opportunity to explore what's underneath it. The episode emphasizes that maintaining the structure of treatment while creating space for honest conversation often leads to more meaningful progress than providing a quick answer. Resources Be sure to sign up for my weekly newsletter!  Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

This week is the last of our summer throwback series. Next week, we will be back with an all-new episode. Until then, check out this vault episode. Originally aired as Episode 166, this vault episode takes an honest look at our relationship with exercise and movement, and why it can become far more complicated than it appears on the surface. For many people, movement stops being something that supports well-being and starts feeling like an obligation, a way to earn food, manage anxiety, maintain control, or even punish themselves. In this episode, we explore the warning signs of compulsive exercise, how movement can become intertwined with eating disorders and perfectionism, and what it means when skipping a workout feels emotionally unbearable. We also talk about the physical and emotional costs of staying stuck in that cycle and the first steps toward building a healthier, more flexible relationship with movement. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]

This week, we are continuing with our summer throwback series. Originally aired as Episode 174, this vault episode explores a question many people ask: What's the difference between disordered eating and an eating disorder? The line isn't always obvious, especially in a culture where restrictive habits, food rules, and body dissatisfaction are often normalized. In this episode, I break down the key differences, the warning signs to watch for, and when seemingly "healthy" behaviors may be crossing into something more serious. Whether you're questioning your own relationship with food or trying to better understand a loved one's experience, this conversation offers practical guidance and reassurance. More than focusing on labels, we explore why the impact these behaviors have on your daily life is what truly matters. Resources Be sure to sign up for my weekly newsletter! Brave on Purpose! - Grab my new book here! Grab my Journal Prompts Here! Looking for a speaker for an upcoming event? Let's chat! Now accepting new clients! Find out if we're a good fit!    LEAVE A REVIEW + help someone who may need this podcast by sharing this episode. Be sure to sign up for my weekly newsletter here! You can connect with me on Instagram @rachelleheinemann, through my website www.rachelleheinemann.com, or email me directly at [email protected]