"Sick Enough" Author Dr. Jennifer Gaudiani on Personalizing Eating Disorder Medical Care

In this episode, Carolyn Costin sits down with Dr. Jen Gaudiani, author of Sick Enough, for a thoughtful conversation about eating disorder recovery and what compassionate care can really look like through a medical lens. 

Together they talk about why so many people struggle with feeling “not sick enough,” how physical and emotional health are deeply connected, and why recovery often takes a more individual, collaborative approach than standard medical systems allow.

Dr. Gaudiani shares insights from her work in eating disorder medicine, including the importance of looking beyond weight and lab results to understand the full picture of someone’s health. She also explains how conditions like ARFID, ADHD, and MCAS can complicate recovery and why carefully listening to each person’s experience matters so much. 

This episode offers a reassuring perspective for anyone wanting a deeper understanding of recovery and the care it deserves.

RECEIVE A 25% DISCOUNT OFF DR. G's BOOK "SICK ENOUGH" 
Use the code to purchase your copy below: TXC26

https://www.routledge.com/Sick-Enough-A-Guide-to-the-Medical-Complications-of-Eating-Disorders-and-Undernutrition/Gaudiani/p/book/9781041036487

LEARN MORE ABOUT THE GAUDIANI CLINIC: https://www.gaudianiclinic.com/

ABOUT DR. JENNIFER GAUDIANI

Jennifer L. Gaudiani, MD, CEDS-C, FAED, is the founder and medical director of the Gaudiani  Clinic. Board certified in internal medicine, she completed her undergraduate degree at Harvard,  medical school at Boston University, and internal medicine residency and chief residency at  Yale. 

Dr. Gaudiani served as the medical director for a highly specialized inpatient medical  stabilization program for adults with anorexia nervosa prior to founding the Gaudiani Clinic in  2016. The Gaudiani Clinic offers specialized, trauma-informed outpatient medical care to  individuals seeking support for eating disorders, undernourishment related to complex  medical issues, and weight-inclusive primary care. The Clinic is based in Colorado is licensed  to practice in almost every US state via telemedicine. 

Dr. Gaudiani has lectured nationally and internationally, has been featured on numerous  podcasts, and is widely published in the scientific literature. The second edition of Dr.  Gaudiani’s popular book, Sick Enough: A Guide to the Medical Complications of Eating  Disorders and Undernutrition was published in November 2025, and the audiobook version that  she recorded came out in February 2026.

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Thank you for listening. Please take a minute to review our helpful links and resources below.

Important Links:

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RECEIVE 20% OFF your purchase of the 8 Keys to Recovering from an Eating Disorder (book).

Recovery Resources and Support:

The National Eating Disorder Association (NEDA)

Project Heal

National Association of Anorexia Nervosa and Associated Disorders (ANAD)

Carolyn's Bio: 

Carolyn Costin is a world-renowned eating disorder clinician, author, and speaker. Recovered from anorexia, she pioneered the belief that full recovery is possible. Founder of Monte Nido, she transformed treatment with a holistic, home-based model. She later founded the Carolyn Costin Institute, training coaches and clinicians worldwide. She has authored six books, ...

Transcript

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SPEAKER_02 0:01

Welcome to Becoming Recovered, Body and Soul, a podcast not only for individuals struggling with eating disorders and body image issues, but for loved ones and professionals trying to help them. I'm Carolyn Coston. I recovered from an eating disorder in my teens and have spent the last few decades helping countless others do the same. Through my work as a therapist, my books, treatment centers I founded, and now my institute where I train and certify eating disorder coaches, I've become an internationally recognized expert. But this podcast is about bringing in the real experts. People from all walks of life who, like me, became recovered themselves. They will be here to provide insights, discuss their journey, and inspire you on yours. This podcast is intended for educational purposes only and is not a replacement for professional therapy or treatment. Please understand that we mostly avoid what might be unnecessarily triggering content, but this is a real show about the reality of eating disorders and recovery. So there is a chance something might be personally triggering. If you're struggling, please reach out to a qualified provider for support. You can also check our resource list. Welcome to Becoming Recovered, Body and Soul. I'm so excited about the guest on my show this episode. She's the first person that I'm interviewing that did not have and recover from her own eating disorder. But she does have lived experience in the sense that she had a sister who recovered from an eating disorder. That's not why I'm having her on the show. I'm having her on the show because she's the very best medical doctor in the whole world for treating patients with eating disorders. And we're going to talk a bit about her new, the second edition of her new book called, well, the new edition of her book called Sick Enough Today. And since I like to start the show with uh some kind of quote, I'm going to start with a quote from her book. And so I'm just going to read it, and then you're going to get to meet her. And here we go. I realized that Western medicine silos body and soul in ways that serves patients poorly, especially those with eating disorders. That is, mental illnesses are typically treated by one set of professionals, and physical illnesses by another set. And the system keeps the two disciplines separate, even though they're inextricably connected. Good medical care must unite body and soul. So true, so beautifully said, and from someone who I'm lucky to call my friend. Welcome, Dr.

SPEAKER_00 2:54

Jin Gadiani, and thank you for being here with me. It is amazing to be here with you. And you know that I love you with all of my heart and have for many, many years.

SPEAKER_02 3:06

Feelings mutual. Listeners, you are in for a treat. I guarantee you're going to walk away having learned something new. I've been in the field for over 45 years. And Jen, every time I hear you speak, every time we work with a patient together, every time we just have a conversation, I learn something new. And so I know people are going to get something from this. Many of the things you talk about in Sick Enough, you know. But, and by the way, that book blew my mind. I already know you when that book blew my mind. So we're going to try to get to some of those, some of those things today.

SPEAKER_00 3:44

Amazing.

SPEAKER_02 3:45

Um, let me just give the listeners a sense about what's coming. We're going to talk about this idea of um, I say you practice soul medicine, and um, we're gonna talk a little bit about what that means. Um, compassionate, individualized, and we're gonna discuss some controversial stuff. Why not? Issues around weight, and I hope we get a little bit to some other diagnosis, mental and physical ones that actually um conflict or complicate the treatment of eating disorders because I think you're a leader in the field. I know you're a leader in the field with some of those things. And then maybe a bit about um eating disorder coaches, because you're someone who deals with that. And so that's dear to my heart. So I'm gonna start with some personal questions. And the first one is why did you specialize in this? How did you come to eating disorder specialization in your medical care?

SPEAKER_01 4:43

Well, it's a story of incredible luck because so many of the best things in our life happen where we maybe keep ourselves open to wonderful opportunities by taking care of ourselves properly. And then when the opportunity lands in our pathway, we can say yes to it instead of saying no to it. So I became an internist because I'm a nerd and I love taking care of the whole human and having uh, you know, being involved in every part of what goes on in someone's body. And I love the educational part. Um, but I had just moved to Denver with my husband and our then toddler child, and um was invited to help participate in uh growing and running the nation's top medical stabilization program for critically ill adults with anorexia nervosa. And I had been primed for this opportunity by the fact that my sister had had an eating disorder for many years, and I had loved on her as she went through her recovery process and felt myself deeply inspired and also worried and sad and concerned and all of those things together, and then watching her get fully recovered, which is the term that I learned from my beloved friend Carolyn Coston. Um, you know, I I heard this opportunity come up. And at the time I had one toddler daughter, I was pregnant with my my other daughter at the time, and um I said, yeah, I'd love to do that. So I spent eight years learning from my beautiful, wonderful patients and then the heads of eating disorder programs that I got to meet in the course of things, which is how you and I met, um, and and how you and I became such beloved friends. And so I learned from these incredible, you know, foundational clinicians as well. And um I fell in love with the whole situation. I love the patients, I love the medicine, I love being able to take care of the whole human while also focusing on a very specific patient population. And then in 2016, for a variety of reasons, I realized it was time to open up an outpatient medical clinic because there were so many folks who in the hospital would say, Dr. G, my care has been terrible medically. People gaslit me. People minimized what I was talking about. I had a patient who had tears running down her face as I told her that her blood tests, which are often totally normal for people with eating disorders, but in her case were very abnormal, had just had a similar panel of labs two weeks prior to her hospitalization. And the PA called and said, you know, you should probably eat some more potato chips and drink some water. Yeah. So, you know, they had they had been mistreated and undertreated. And um, and so I started this lovely outpatient clinic in Denver, Colorado, where my partners and I now see patients from 48 states. We're open to the final two, we just don't have any patients from there. And um, we take care of the medical side of people's eating disorders, and we sort of become their primary care doctor and collaborate with their home therapist and dietitian. And sometimes it's someone with an eating disorder who has medical stuff in the way of recovery. And sometimes it's someone with a really complex medical illness who has become undernourished. And we know all sorts of things happen in the mind and body when that's the case, but they need someone who can hold the renourishing, whether or not that involves weight restoration, um, you know, whether that's part of their pathway or not, and also support them as they get better from the thing that made them become undernourished.

SPEAKER_02 8:31

So that's neat. You know, I think you've answered about five of my next questions, but that's perfect. And then I don't have to ask them. There's a few things you said I want to point out. Um, one of them was, you know, learning from clinicians. And I I want you to know I'm giving you an honorary therapist degree. Uh, you know what I mean? You're you're you're the closest to a therapist as any doctor I've never met in terms of the way you sit with people, listen to people, learn with people, deal with both their psychological and their spiritual issues. And I'm guessing from what you were saying, um, I never heard you describe why you uh named the book Sick Enough, but I'm guessing by some of the things you just said that you ran across, you know, early in medicine about the the the the stuff that goes down. I mean, I remember you you let me do that talk once in Colorado, uh where the title, I think I pissed some doctors off. Well, I know I did when I said, I can't believe your doctor said that, I did that whole talk about it. Love that talk. But um, tell the listeners why you called the book sick enough, because I I think that's important.

SPEAKER_01 9:53

You know, what I heard so consistently from my patients, whether they were in my hospital program or in my outpatient program, was Dr. G, I don't believe I'm sick enough for everyone to be this concerned. I don't think I'm sick enough to be asked to change my behaviors. I'm embarrassed that people were giving me this attention because I'm just not that sick. And so I thought, gosh, you know, I learned from people like you so much about the mental illness side of this. And I understood that part of the psychopathology is this denial of illness severity. And I thought, gosh, what an interesting opportunity I have as an internal medicine physician to help bring objective evidence of body suffering to the individual and say, this is how this links up with your behaviors. And some of that objective evidence is measurable and some of it is narrative. I was an English major who focused on close reading poetry. So I love a story. And in listening deeply to my patient's stories, I got to pick out the symptoms that I said, let's pause there for a second. When you tell me that your tummy is so bloated and full after half a sandwich, that really means something to me. Let me tell you what that means and contextualize it into your behaviors, regardless of what body weight you have. If you are undernourishing like this, of course you're going to develop gastroparesis for these reasons. And so when I named the book Sick Enough, it was such a familiar phrase to any English speaker who has had an eating disorder or loved someone with an eating disorder, because so many folks have heard, I'm not sick enough for you to feel this worried about me. I'm not sick enough to go to treatment. I'm not sick enough to change my behavior, to eat more, to purge less. You know, the body weight that doesn't allow you to go to treatment. You don't have abnormal labs, you're not that bad. So it's it's two-sided.

SPEAKER_02 12:10

I mean, that was one of the things I said and I pointed out in the talk is, you know, doctors saying to people, well, you look great, you know. So it does work both ways. And what I often say to people with eating disorders that are saying, you know, you know, that thing, I'm not sick enough. I say, sick enough, like with anorexia nervosa, sick enough means you die from your starvation. That's when, you know, you're not going to reach it until that point. Um, so uh let's I want to go back a minute to this whole idea about the body and soul. Because you you there's a quote in your book where you said the body and soul will find a way to force patients to hold still and recharge something like that. And can you can you explain that a little bit?

SPEAKER_01 12:58

Yeah. Gosh, you know, for so many reasons, I've become a deep believer in the connection of body and soul. And the idea that one needs to be a believer or not seems so silly because it's it's obviously they are connected, you know. Um and what I observe is that when I see patients living out an internalized belief that they're not allowed to rest, they're not allowed to take care of themselves, they have to take it care of everyone else, they're not allowed to get space from toxic relationships or process traumatic experiences, whatever it might be, when they're driving themselves and not listening to their needs, eventually their body's gonna bench them. Because bodies and souls don't do that. You can't keep beating up on yourself endlessly without respite and have your body and soul chirpy, get up the next morning and be like, okay, let's do it again. It will bench you. It will, it will give you abdominal pain to the point where you stay in bed, it will give you exhaustion to the point where even if you had all of your turbo boosters on, you couldn't leave the house. It will bench you. And and it's a way of saying, like, stop. I can't bear what you're asking me to do anymore. And I need you to take some reflection. And what I encourage my patients is before your body benches you, let's let's like acknowledge what you need and start taking care of yourself.

SPEAKER_02 14:36

Yeah, so your body doesn't have to do it for you. That's it. Yeah, that's exactly right. Um, so I want to talk, uh, I there's so many things. I want to talk about some cautions, you know, that that you've seen and stuff in the field. Um, but before we get there, uh we did this talk once together about analogies. And sometimes I I was I was so we were so tickled when we found out each other used analogies all the time. So I thought, could you maybe pick a few, a couple of your favorite analogies when you're trying to explain something? Because you get through to patients when you do it that way. They can see it in a different way. So there are there any that come to mind that stick out as your favorites?

SPEAKER_01 15:17

Yeah, I would love to. I actually went over this one, I think, twice just during clinic today. Um, this is an analogy that helps us understand why when we're more depleted, certain symptoms get worse. It could be mental health symptoms, it could be physical symptoms. And the analogy is this: I learned this from a neurologist. Imagine a fish tank, and there are corals in the fish tank of different heights. If the water is full in the fish tank, none of the coral tips break through the surface of the water. And that's the state in which someone has few or baseline symptoms. But as the water level drops and more and more coral tips show up above the surface of the water, that's symptoms. And the level of the water is a metaphor for how resourced we are. The tank is full when we are rested, nourished, hydrated. We haven't gotten too hot or too cold, we're not sitting with toxic stress. And when our tank is full, we're gonna have relatively few symptoms. But as the tank, as the water goes down, suddenly we're like, wait, why does my stomach hurt again? Suddenly we're like, why is my POTS, my postural orthostatic tachycardia syndrome worse again? Um, why is my mood so anxious? Why is my OCD so mean right now? And it's because our water tank is down. And sometimes it feels like, oh my gosh, everything feels so chaotic. What's my agency here? And the ED wants to be like, I have a great idea. How about behaviors? Yeah. But instead, we can say, I'm gonna learn what replenishes me. Only I can say what replenishes me uniquely. And I'm gonna listen to that. I'm gonna be kind about the fact that I have a need, and I'm going to act. I'm gonna take agency and I'm gonna get better sleep. I'm gonna hydrate myself, I'm gonna take my meds on time, I'm going to nourish properly, and I'm gonna take a break from social media, whatever raises the water, and then you can't see those coral tips anymore.

SPEAKER_02 17:30

So perfect. You're giving me a new one. I hey, let's write a book one day about one day when we all have all this time of just analogies. I've thought about that a lot. That would be fun. Would love. Um, so let's talk about some cautions. Um, like something you wish primary eating disorder doctors knew, and mistakes of well-meaning physicians. Um, it's not that I really want to bash on other people, but I I'm hoping that listeners out there, if they're suffering or they have loved ones are suffering or their conditions, learn some of these take-home pointers. You know, are there any things that come to mind about, you know, what you'd like to tell primary care doctors out there?

SPEAKER_01 18:20

I mean, in a cheeky way, what I want to do is be like it's all here in this book called Sick Enough.

SPEAKER_02 18:27

You know what? Good point. But I'm telling therapists to read it, I'm telling coaches to read it, because there are so many things in that book.

SPEAKER_01 18:35

But uh But but yes, no, to to be sincere. Um I think one of the most valuable things that I could, if I had a magic wand for, and it and it was of limited powers, um, that I would sort of waiver over all of the pediatricians and primary care providers out there, would be to understand that eating disorders are not synonymous with low body weight. So one of the most common things that I see that's a mistake is um still, let's, yeah, still, unfortunately, is that someone of any age, but I particularly see it in the teenagers, um, they for whatever reason start down a pathway of restriction. And they may have started in a body size that was larger. And when their parent says, gosh, you know, wait, I've become concerned. For a while, I was I was thinking, oh, you're eating healthy, and that's really great. Now I'm like, uh-oh, something seems wrong. And they take their kid to the pediatrician, and the pediatrician does a weight and goes, Well, I mean, you've lost some weight, but you're not underweight. In fact, you know, and God knows this would never emerge from my lips. I am quoting another theoretical doctor, you needed to lose that weight. So keep going. Good job. You know, they miss atypical anorexia, they miss bulimia. And um, that's just because the person's not showing up emaciated. And we have this vision in our head as medical providers that that's what an eating disorder is. But the vast proportion of people with eating disorders are not visibly underweight. So I think if I could instill that, and if I could instill um just a real decrease in weight stigma that takes place in medicine, you know, where one of our beloved patients returns from treatment and goes to the doctor, and the doctor or the nurse says something catastrophic about their weight, and you know, sort of the house of cards starts to come tumbling down. Or when somebody who's in a larger body has, you know, is is given diet tips by their primary provider, even though they came in there intending to disclose an eating disorder, that I would change. And finally, I think I would just, if I could have primary care providers be able to recognize eating disorders and then just refer to a community therapist or dietitian who specializes and just say, like, honestly, I don't know what to do here. Don't. Yeah. But I'm willing to take your lead, dietitian or therapist, and I'll do the best I can because you know it's a limited system, and this person might not have geographic access or insurance access to someone else. But I'll listen to you because the therapists and the dietitians are so smart about this stuff, but oftentimes the medical provider doesn't want to listen to them.

SPEAKER_02 21:22

Well, I think, in all fairness, you know, I remember when I did that talk and I looked up how much training a doctor gets in eating disorders in medical school on a zippo, you know. So they don't know, but I think you're right about find somebody who does, you know, get them on the team and and work with them and don't be insulted when they direct you in certain ways.

SPEAKER_01 21:45

Right. You know, I don't know so many things. And I I, you know, I mean, I just don't know infinite things. But um, when I don't know something, I try to find someone who does so that we can be a resource to the patient. And I think it's it's when doctors both. Don't know and don't have the humility to be like, gosh, it feels like something's going on here. You say you're concerned, loved one, and you're the patient here may or may not be expressing concern, but I can tell there's something going on that I don't quite get. Let's try and find someone who does know about this stuff, and then I'll take their lead. I don't expect everyone to be a specialist in everything. That's crazy. But if they can just say, like, it feels like something's not right here, let me try to connect you, even if by telehealth, with a therapist and a dietitian who really know this.

SPEAKER_02 22:35

Yeah, and it's not that hard anymore, not like it used to be. It used to be hard to find a special, you know, therapist and dietitians. Um, okay, you mentioned earlier about when labs are normal and the person is still sick. And I remember an analogy I gave was someone is cutting down a tree from this side and they're cutting it and cutting it. And you don't see anything, the tree's still standing. You don't know till it breaks through. But what are some of those? Why is that? And um, what are is there anything else you want to say to expand on that? Something to watch out for, or I don't know, maybe you feel like you said enough about it, but anything else to that?

SPEAKER_01 23:18

I love that metaphor so much. I I had forgotten that one. It's such a good one. Um, yeah, what I like to tell my patients is the story about why our bodies are such beautiful miracles and and how they're going to respond to eating disorder behaviors in ways that try to save our lives. And sometimes that's really beneficial, and sometimes it's it's not so helpful to the recovery process. But I say, you know, we evolved as a species in a time of want, not plenty. And as a result, we have the most incredibly intricate sensors all through our brain and body that try to figure out when we're not nourishing enough, regardless of what our body size is. And when one of those sensors gets tripped, our psychology and our physiology change to save our lives. So when someone is undernourishing, regardless of their body size, their cave person brain goes, I got you. I'm gonna change how you use energy. I'm gonna decrease blood flow to your hands and feet so that we're not losing energy from them because they're not super important to survival right now. And I'm gonna slow your digestion so we're not burning an extra calorie on a wriggle of your gut. I'm gonna slow your heart rate. I'm gonna make you kind of tired, and I'm also gonna make you kind of paranoid and serious and anxious because starved mammals aren't playful or creative. And so it does these beautiful things that are as inevitable as our drive to take a next breath, but it tries to keep us okay. And when we're purely restricting, the lads are almost always normal because the body is doing such beautiful, miraculous work to keep things okay until you get through the desert and get back to food. Um, and when people purge, by contrast, that throws the whole homeostasis off because it can radically change your hydration status and your electrolyte status. And we don't have any capacity to like accommodate that, except in a particular condition when folks who purge for a long time end up raising a hormone called aldosterone to hold on to fluid and to sodium to salt that they consume, which is why people who stop purging can suddenly increase their weight and get lots and lots of fluid weight and swelling. But the point is that I keep trying to bring it back. Like so much of society tells us mistrust your body. You have to wrangle your body, your body is going to betray you. But on the contrary, our bodies are constantly trying to work on our best behalf.

SPEAKER_02 26:13

And I think when you do that, you help people start to appreciate their body more, start to see the miracle that it is. Instead of, you know, these things happening, you know, are bad. You know, I think you help people see what a magnificent system it is, you know, and that is a form of appreciation of the body, which needs to extend in a lot of ways with people with eating disorders, you know. Um, okay, uh let's talk about uh let's talk about RFID for a minute. By the way, you mentioned weight, and that's going to be one of the things, one of the controversial things I was gonna talk about. But um, I think you say some things about RFID in the book that are, I mean, yeah, I think a little maybe not controversial, but they're new and improved. Their ways of looking at RFID, and when I read it, of course I liked it because I went, I do that. And uh can you can you just say what RFID is? Because people who ask me a lot about it, um, you know, and look at my definition of recovered, where it says you'll no longer uh compromise your health or betray your soul to look a certain size or um be a certain shape or uh a number on the scale. Number on the scale, be a certain shape isn't part of RFID. I mean, sometimes RFID can go into that, but will you talk a little bit specifically about what RFID is? And then if you don't bring it up, I'm gonna bring up what I think you say that is um challenging to other professionals.

SPEAKER_01 27:54

Yeah, um I'm I'm so curious the things that feel challenging, but essentially avoidant restrictive food intake disorder is a DSM diagnosis of an eating disorder that can describe an astonishingly diverse group of people. So one group of people could be young children, more often boys than girls, but generally children who are super, super picky. And they are so picky that they may become malnourished, and at the very least, it really impairs their social function. It may describe a group of kids who have autism, and by having autism, they have certain textural or color, flavor, temperature uh experiences that make a number of different foods really aversive to them, and so they avoid them. There are people who just don't have an appetite or who have had such a relationship in their family of origin with food or eating or fullness that that food just becomes really scary, and it has nothing to do with body image, at least at the beginning, and everything to do with like, wow, this is not a safe thing for me to do. But then you also have this incredibly interesting, diverse group of adults, because I more often see them as they become adults, who have medical problems that make eating so miserable that it's just negative conditioning, like any other negative conditioning. You know, if you if you shock someone every time they reach for an apple, they will stop reaching for an apple. And um they just learn like this isn't safe. So, you know, people with really complex digestive systems in particular, people with mast cell activation syndrome, people with hypermobile Ailer-Stanlos syndrome, people with dysautonomia, they feel bad when they eat, and so they eat less. And then physiologic things happen and psychological things happen, and they can get, you know, sort of um more distorted about body image. And of course, society around them is always distorted about body image. Um, but I think that there's so many things that we can do to just show up pragmatically for these individuals and be like, what would help? Like one of my favorite questions to ask is what's in your way so that I can help and try to remove the barrier medically.

SPEAKER_02 30:23

Well, okay, I'll tell you that that's showing up individually for people. And I think that comes across over and over and over in sick enough, this individual care, not a prescriptive kind of care. And the thing I think you say that that seems uh controversial to me in a way, is the thing about one being so collaborative with them, not seeing them at all as being manipulative, they have fear. And you don't have to push for them to eat every kind of variety of food. You you you it's it's about getting your own agenda out of the way and working with them in an individual way. And I've read some other stuff about RFID where people are talking about that and trying to promote that, like um helping parents understand look, this is not your kid trying to manipulate you. This is a fear-based thing. But here's what I think about that. I think that treating even other eating disorders like that is the right way to go. In other words, people are saying it a lot about RFID, like you don't have to push for all variety, don't think of it as manipulation, don't, you know, punish, get your agenda out of the way. I think if we treat all eating disorders like that, they're gonna be better. Because we do the same thing for like when we have certain meal plans that everybody has to follow, or the amount of weight gain they have to have in certain programs, you know, in a week, or insurance cuts them out. You know what I'm saying.

SPEAKER_01 32:05

I I love that so much. I couldn't agree more. And and there's a really tricky ethical piece to this, though. And I think this is a way of caring for patients that is more easily done by clinicians with a lot of experience like you and me than it is by somebody straight out of school. Because, you know, along a spectrum of treatment philosophies, it's easy for someone to say, now wait a second, where do we end up with enablement of an eating disorder versus individualized care? Where do we end up holding people in their illness versus really leaning on them hard to get sort of quote unquote well in whatever way that's measured as swiftly as possible? And what I've seen my whole career, and again, I learned so much of this from you too, Carolyn, is when you really listen to somebody and you really hear what's important to you, and how is the eating disorder getting in the way of that? And you address the things that are values-oriented for the individual first, and you acknowledge and listen to what their particular fears are, and you try to hold them close the whole time in order to understand how vulnerable it is to trust and to change behaviors, you end up in this lovely collaboration, even when the eating disorder is being an asshole. You know, you end up in this lovely collaboration where you can talk through the times the ED is raging. You know, the number of times that my patients and I have just exchanged a rueful laugh when they're like, So uh, this is happening and this is happening and this is happening, but I'm definitely fine. And I just look at them and I sort of start to chuckle, and then they start to chuckle too, and I'm like, yeah, I mean, no, you know, and and and then we're like, let's go back to the basics. Let's remember what are your identities? Your identity is an aunt, it's a dancer, it's a professional. Let's start there and where can we start to rebuild back?

SPEAKER_02 34:12

But I always don't, you know, not it's bringing the healthy self in, which is what I always say. You know, it's not about getting rid of the eating disorder self. You got to get rid of that. It's about connecting with their healthy self, connecting with their soul self and bringing that up, blowing new life into it. I think it's hard to um get rid of something when you're not looking at what are you replacing it with, what's really there for you, your values and what you want to do, and and all of that stuff. And I think, and I think that's what you do as a physician. But it takes time, you know, it takes a lot of time and it it it moves away from just following, you know, evidence-based practices. You know what I mean? It's not and you're a physician, you're not a therapist, but I told you already you're an honorary therapist. But I think you cannot separate these two. I don't even see how you can work with one without taking in the other, you know?

SPEAKER_01 35:14

Yeah, I think that's right. I think that's exactly right. And um, and it's an ongoing discussion. You know, you don't set the course of the ship and then grit your teeth and blindly navigate. What's better is to tell the patient, you're the captain of your ship. I want to be the wind in your sails. Let's keep figuring out where we are on this ocean and let's like decide where are we navigating to. And sometimes the goal is let's just get like a little bit away from where we are today, because big navigation, way too overwhelming. Um, and and it's just this really, really collaborative process that you're right, takes time and takes resources, and many don't have access to that. So, in some ways, you know, coming back to the book briefly, the reason I wrote it is so that families can empower themselves and individuals can empower themselves against some of the inadequacies of the system, and so that providers who do want to learn this can get better at it because there's only this finite number of individuals whom I can see directly, but I can reach and help and improve, I hope, the recovery patterns of a lot more people by putting that book out into the world. Just like, you know, so many of my patients say, Oh, Dr. G, I started reading this amazing book. It's called The Eight Keys by Carolyn Coston. It's blowing my mind. And I'm like, oh, there she is, you know, she's not sitting on the couch in front of you, but she is there helping you recover.

SPEAKER_02 36:43

Well, that's exactly right. I thought the same thing. I'm saying the same things over and over. And and even in uh, yeah, in a few, in the even going back to the original eating disorder source book, the first one in 1996, I thought, I gotta get some of this stuff out there. 1996, and at that point when I first started writing it, there weren't a lot of books out, you know. Um, I want to go back to collaboration because you mentioned something about enabling, you know, versus supporting. And that uh, you know, uh people sometimes say you can't um that they use this, you can't negotiate with a terrorist. Have you heard that? And when you're trying, and and I'm thinking, if you don't, that's what we have negotiators for therapists. That's why negotiators are trained to work with therapists. You don't give them every with everything, but if you don't collaborate, and I think there's a lot of research that people have not been exposed to that shows collaborating is one of the number one reasons for success in psychotherapy, anyway, and the therapeutic relationship. Those two things stand out as high as evidence-based practices in in my field. So it is that thing where you're slowly, you're collaborating, and you might be going slower than other people think you should go, but you still keep the end goal in mind, you know, you still push for just a little bit more, even if it's a tiny bit more at first. And and I think that's why, I mean, I'll just say it, I think that's why you and I have had success in the field, because of that very thing.

SPEAKER_01 38:21

It depends a little bit on what your your end goals are. If you're a clinician in a higher level of care and all your goal is is to make sure someone, let's say with anorexia, gains two to four pounds a week every single week until they're at their exact sort of, you know, ideal object. There you go.

SPEAKER_02 38:41

Exact whatever it is.

SPEAKER_01 38:43

Yeah, yeah. Um, then you're gonna use one set of techniques and and you're gonna say, at the end of a stay, I want someone to have these exact parameters because that's what we consider recovered. That's what we consider done. Um, but if you're somebody who wants someone to heal deeply from within and ultimately in the long term end up as recovered as they feel they can get, then your strategy is different. Sometimes I use a metaphor of wound care, which may or may not be something that people are totally familiar with. But if someone has a deep wound and they just have stitches put over the surface of the skin, from the outside, it's gonna look like it's knitting. But on the inside, you've got this whole pocket of tissue that never healed. And so at the least stress, the scar breaks open. It's not healed. But if you heal from within, which is indeed what we do with wound healing, where you pack it and you take care of it, and it slowly, slowly, slowly comes together and heals from within. If you're looking at the skin on the outside, it looks open until the day it's actually truly healed. But it's been healing deep from inside. So there's a lot of different ways people can heal. And I love helping them with that. You know, if I can help their mast cell activation syndrome and their pots and make it less miserable in their tummy for them to eat, we might not make a ton of weight progress or eating behavior progress until one day they're like, holy shit, I went out to Thai food with my parents tonight.

unknown 40:25

Yeah.

SPEAKER_01 40:26

You know, and that's what makes the difference.

SPEAKER_02 40:30

It won't surprise you to know I did a talk once called Healing from the Inside Out. That's not gonna surprise you. I I I I want to come and do another talk with you someday. Um okay, you mentioned mast cell, you mentioned pots. There's uh there's still uh I want to maybe get to those, El or Stanloff's, you know, gluten. Uh I don't know how much we're gonna have time for, but so think about that. Well, which one you might want to talk about? Um, or look, people will just have to read the book. Um, but I want to say something else about weight. And you talked about weight stigma and weight inclusive care, but there's something in the book that blew my mind about people asking you all the time, when I have a transgender client, which parameter in terms of the charts and graphs am I supposed to use? Their gender at birth or the their new identity gender, you know? And I went, oh my God, I can't believe that. And your answer, um, I can probably find the quote if you don't remember it exactly. Do you remember what you wrote?

SPEAKER_01 41:37

I mean, I remember my essential philosophy about it, but I'm happy to have to find it in the book. No, go ahead. Just say it. Yeah, I don't have to read the quote. I mean, my basic philosophy about that is like, cut the bullshit. Why are we even talking about specific benchmarks, this, that, and the other? Like, let's allow a human to recover into a body that feels as acceptable to them as the situation allows. And let's just watch the whole human and see that the parameters psychologically and medically have gone the right direction.

SPEAKER_02 42:15

Yeah. Okay, I'm gonna read the quote. Okay, okay, read the quote. Even though you did a good job, I'm gonna read it because it's so good. I think that transgender individuals with eating disorders have achieved a reasonable weight range when they consistently consume adequate nutrition, can move for joy, are medically stable, and when the weight range is reasonably acceptable to both patient and treatment team. Again, I look at this and I go, everybody, everybody, you you say it in defending, you say a lot of things in defending certain populations, you know, minority populations, like transgender or ARFIT or whatever. And really what you're what you do is you do that for everybody. I say you do that for everybody. And that's what I try to do for everybody. And that's what gets back to individualized, collaborative, compassionate, but straightforward, truth without judgment care. It's not like you let people get away with anything. It's not like you don't tell them the truth. It's not like you don't call them out on their bullshit. That's the thing about this kind of care. Sometimes people think it has to be one way or the other, and there's a way that's important to combine both both. You still have to be a straight shooter and you still have to set limits and boundaries when you have to. All of the above. Um, in RFID, I want to go back to RFID for a minute because it was going to be my lead in to talk about coaching. There's so much talk about exposure with RFID, but we know exposure is important for, you know, all kinds of diagnoses. And so, as you know, through My the Carolyn Coston Institute. I'm training coaches. 98% of them have had an eating disorder and are recovered, and they do all kinds of things. And you are one of the clinics who and people who have embraced it and used coaches. So I wondered if you could talk about that a little bit, how you add them as part of the team.

SPEAKER_01 44:23

Oh, I love working with coaches. I love working with your coaches specifically. I think what you told me so succinctly when you were teaching me about this originally is that the clinical team might give the patient the what there is to do, but the coach shows them how. And I just I've so appreciated that. When resources allow for a family to work with a coach, it's somebody whom the patient can rely on when it's been a week since they saw their clinician. And the real glow that they had coming out of that session is starting to wane, and the eating disorder is getting a little loud. And they're like, why was it again that I needed to eat this portion? And is that portion really what my dietitian said? And then they text their coach, and their coach goes, Hi love. Yep, we're gonna portion it out. We're gonna eat it. I'll be here with you while you do it. I'll go to the grocery store so you can buy the stuff you need to make that snack. I'm gonna help you organize things because your ADHD is all haywire right now, and it's really making recovery work tricky. Like the coach is just the person who helps them actually effectuate recovery behaviors. And I deem it a complete joy whenever I have the fortune to work with a coach.

SPEAKER_02 45:48

Oh, that's so nice. Well, you know, it was like a missing gap in the field. And, you know, we had all, you know, sober coaches and life coaches and, you know, all kinds of coaches. And um, but I didn't know how it was gonna go. And you've embraced it and it's been helpful, and I'm I'm really so glad to hear that, you know. And I think, I think I just call it they're just sort of in the trenches. You know, I did a lot of that. Uh we do the best we can as ourselves, as clinicians, but we can't be there all the time, you know, in the middle of the night when someone feels like, you know, binging and purging. Anyway, so yeah, I really appreciate that you and the and the Gaudioni Clinic have have taken that up. Okay, so have you thought uh, and you mentioned ADHD in there, uh, there are any of those something you want? I mean, there's mast cell pots, ADHD, there's there's some really important things you say about all of those. Is there, since we have maybe, I don't know, 10 minutes or so, um, because I don't want to take too much of your time that I've already taken. Uh, any of those you want to talk a little bit about?

SPEAKER_01 47:05

Yes. I'll say very briefly, but I'm not gonna really expound on this, that I think diagnosing and treating mast cell activation syndrome in those with eating disorders might end up being the most important medical breakthrough in the eating disorder field that I've ever witnessed. Because I think that up to one in five, maybe more, people with eating disorders have MCAS. And because a lot of doctors don't believe in it, they're undiagnosed and they're untreated, but it makes food really unpleasant. And if you can do some of the often very simple things, the book goes into detail, it has a whole chapter to help people with mast cell, you may just present the walkway of the rest of their recovery to them in ways that I think are so important. So that's just like that's like a teaser for people to go read the chapter on MCAS. If if they have a history of rashes, food reactions, weird sort of allergic-like stuff that's not that consistent, reactions to heat, reactions to alcohol, digestive stuff no one can figure out. Please read the chapter on mast cell. Um, but I think what I'd love to talk about, and it's a favorite soapbox of mine right now, is ADHD.

SPEAKER_02 48:29

Yeah, I wanted to talk about that because again, there's some things in the book that are like, wow, you go. And I'll bring up the ones if if you don't.

SPEAKER_01 48:37

Right. Um, so here's what I've learned because holy moly, have I had a lot to learn. I thought I knew about the medical complications of eating disorders when I started this clinic. I think I've probably learned 85% of my current knowledge base since starting it. So I mean, holy humbling. Um, but what I've learned from my patients is this. Um, and I think this is more common in my female patients, because I think boys are maybe a little more easily identified or paid attention to on masks, uh, sorry, on ADHD stuff. Um, but the girls, here, here's the story that I've I've come to help to build with my patients' help. Everyone's different, but this is the story. A little girl, super smart, really, really intentional, um, a strong sense of shame, um, starts to realize early on in school that her peers do things more easily than she does, and that she has to work a lot harder to get what they seem to get more easily. But she's got high standards and she's from a family with high standards, and so she really starts putting a lot of structures in place about what she can and can't do because she has to really, really work hard to do the school stuff that a lot of her classmates are doing well. And she feels a sense of shame about herself. Like, I'm I must be really wrong somehow. However, oftentimes on the athletic field, she's their equal. And so movement becomes a positive. And indeed, when she moves, something is soothed in her that she hadn't had soothed before. And so movement is sort of a double positive. She's equal to her peers and she feels better body and soul after she's moved her body. And you hit middle school and hormones start up, and school gets more complicated, and other things get more complicated, and she falls farther behind, or it's harder for her to keep up with her peers. But man, she really digs in and she gets more rule-bound and she finds ways to get it done and she gets good grades. And she does that until something happens. It could be pneumonia, it could be a GI illness, it could be a coach saying something, and she might eat a little less. And as she finds that she eats less, whatever's happening in her brain goes quieter. The intensive chaos gets quieter. The inability to sort of keep thoughts together gets quieter, and she's like, oh man, this feels better. And so the the refrigerator, the brain refrigerator that is eating disorder behaviors, numbs out and distracts from what has been ADHD all along. But nobody saw it because she's she's achieving in ways that we sort of roughly say, like, oh, these are checkboxes of achieving of an achieving kid. And so all of this comes together with the rising sense of shame and and inability to do stuff, and it seems so disparate from from how the brain works and movement. For people who are neurodiverse, rocking, swinging, bouncing, moving is deeply restful to the autonomic nervous system. This is ADHD, this is people with autism. And so when she finally comes to the attention of an eating disorder professional, they hear all of her behaviors and all of her rules and all of her rituals, and they say, Well, you have OCD because you've got so many rules. When in fact, that may it might have emerged, it often does, but that may have been the scaffolding that made her life manageable in her ADHD and it just stuck. They say that she's an over-exerciser and a compulsive mover, and they say, Don't move. And they tell her, don't worry, as soon as you eat more and gain weight back, you're gonna feel better. But as soon as her brain starts to come out of the refrigerator, it feels like shit. It's so chaotic, and it reinforces the message that the world is totally out of control and the only thing to control is eating. And people just go, anorexia, anorexia, arphid, atypical anorexia, bulimia. But this whole time, the like underlying situation was ADHD. And then even if someone is like, huh, you know what? If I run you through the DSM on ADHD and you actually like pass, and I'm gonna ignore that little pesky thing at the bottom that says, no other conditions better explain this, because of course an eating disorder can explain attention and hyperactivity and all this stuff. Even if someone says, gosh, you might have ADHD, the psychiatrist is almost invariably gonna say, Well, we can't possibly, oh, listen to my man voice when I do that. Apparently, I was there. We can't possibly use a stimulant because it's gonna change your appetite. And what I say is, since when was an eating disorder about appetite? Like some with RFID, right?

SPEAKER_02 53:49

Exactly. This is a controversial thing I wanted you to talk about. It's exactly right. We use stimulant medication and movement at Montanito. Yes. When I was learning Montanito.

SPEAKER_01 54:00

I use stimulant medications and movement in people who are actively recovering even from restrictive underweight eating disorders. And I've been humbled a zillion times. I've had patients in my service for five years whom I love and I know the name of their dog's mother. You know, I mean, I know everything about them. But suddenly one day they say something and I'm like, oh, my fox ears just perked up. Wait, wait, wait, wait, wait. I have questions to ask you. And we go through it, and I'm like, holy shit, I think I've been missing ADHD in you all this time. Do you want to try a stimulant? And if they live in state, I can prescribe it. I don't have to rely on anybody else. Um, and sometimes it's not good for them, but sometimes they're like, this changes everything.

SPEAKER_02 54:48

Like, yeah. And the thing is, you watch for that, you know, we watch for that. If someone lost their appetite and uh started losing weight on it, and we go, okay, it's not right, maybe we try one or two other ones to see if that would work better. Um, but you see what I mean by there were so many aha moments that I had reading the book, things that we, you and I haven't had a chance to talk about in years, and things that are we're growing and we're learning. And the thing I think that people will take away so much from this conversation is the idea that eating disorders, I I want to even say rarely come with just the eating disorder diagnosis. There are so many other things happening in the person's life, and it's so important to look for them. I mean, all the way to people having, you know, been born with a stomach that's a bit twisted, and then you know what I mean? There's so many things, and you have to go through and really, it's it's about assessments and listening and um being open to stretching what you think you know, you know, half of it.

SPEAKER_01 55:56

You know, just to bat just to like follow on that, so many of their providers say we can't address or even diagnose other things until you've recovered from your eating disorder. I know. Because it masquerades. And I'm like, I know, bitches, you have to do it all at once. Because it works. If you're not addressing those other things, recovery is out of reach.

SPEAKER_02 56:18

Okay, this is the silo thing that I that I opened the the show quote with. The if you do it in silos. And I noticed the same thing early on, and maybe I'll even do a show on on substance abuse and eating disorders, because people would say, Oh, you have to treat one. And there's the camp that said you have to do the substance abuse thing first. No, you have to do the eating disorder one first. And it's like, sorry, it's complex, but you have to be dealing with them both, you know? Well, look, we we we live in a situation we we have decided to have our paths are working with people who are complex and whose illnesses, and look, everybody is complex, you know. But I think the thing about this is getting down to the humanness involved in it all. And I think I'm so glad you're in the world, you know, for that reason. I told somebody the other day who I was interviewing for this podcast, and I said, let me just put it this way if if if I had a family member who got sick and called me about a physician, Jen is who I would send them to. And I really, really mean that. So I think I I think you've given people a lot to um grab onto in this episode, but I also think they're gonna want to go and get more. I have a few more um kind of final questions I want to ask you. And and one is how working in the field has changed you personally massively.

SPEAKER_01 57:49

Um of course I have done my own independent therapy work, which is invaluable, but just listening to my patients and hearing an extreme version of many of the traits I have myself. You know, I dodge an eating disorder by complete fortune. I have all of the setups for it. Um and and I realized, oh, you know, through my whole life, I kind of believed that if I were a little bit mean to myself and I stayed critical, that was being rigorous. That was being accomplished, that was showing gratitude for all that I've been given. If I just really work harder than everyone else. And I have come to be so much gentler and kinder to myself. I'm almost 50 now, and um, I'm really good at being gentle and kind and generous with myself now because I have seen it's not rigorous to be mean to yourself. Yes, you can say, I didn't do that right. I want to do this better, I can improve this. Of course, that's a wonderful thing to do. And I embrace the time when I am wrong and I can make repair work with a patient and say, I'm so sorry, I really got that wrong with you. But I'm not mean to myself about it. And it's really influenced me as a parent as well. My girls are 20 and 17, and I feel like my role as their mom was so enriched by the lessons that my patients taught me around validation. You know, in my home now, one of the commonest questions we ask each other when someone is grumpy or frustrated is, what do you need right now? And that was not a question that was asked of me in my youth, because it was expected that as I was raised with privilege, I had everything I could possibly need and I couldn't possibly need anything else. And so that was never asked. But what do you need right now is such an important question. And so as I see my girls thrive and come into their own and be such fierce, strong women, I feel really, really grateful for the pathway in this field.

SPEAKER_02 1:00:00

Yeah, I think that we, I mean, that's practicing what we preach, isn't it? I mean, age-old uh metaphor or saying or whatever you want to call it, but that is what it is. I always talk about how my eating disorder was one of my best teachers in in the same kind of way, but also in trying to help others. Um, okay, a couple more things. What advice would you give someone looking for a doctor? Because people are gonna listen to this and think, I want to find a doctor like that. Um, there's always you and your clinic, but um, and we'll put uh stuff up for how to access you and all that in the in the show notes. Um, but any advice you have for someone, what do they look for in a doctor?

SPEAKER_01 1:00:48

I get this question a lot, and it's tricky. Um some of my best advice is within whatever insurance network you have, find a nurse practitioner or a physician assistant who has space and and call the clinic and say, like, who is your most creative, who is your most compassionate, who is your kindest NP or PA? And I'd like to book an appointment with them. Because if the person has the temperamental setup to be compassionate and kind and loved by their patients, most likely that's because they're curious and they're not defended. And if somebody goes and says, hey, look, I have an eating disorder, I have some medical complexity, I don't expect you to be an expert in this. But what I'd like you to do is be an ally to me as the only prescriber on the team and to my therapist and dietitian, and just be open. When I have something to teach you, be open to it and let's try this together. And in such a situation, a lot of good can be done. So I think that's a really good place to start.

SPEAKER_02 1:01:57

That is a really good answer. And I'm really glad I asked, you know. Um, okay, any questions you have for me?

SPEAKER_01 1:02:05

Oh my God. I mean, yes, when can I next hang out with you for one week straight and just curl up and cuddle up and tell stories and laugh together? And, you know, I just I love you so much, and I'm so proud of your what you're doing with this podcast.

SPEAKER_02 1:02:21

Well, I will try. I will try to figure out a plan. And uh it will have to do when I'm no longer trying to get days in Tasmania for my dual citizenship, but it will happen probably. I'm just gonna answer that question 2027 sometime, because I would really like to do that. It's a date. And then the question I ask everybody at the very end: what are a couple things that you do for your own body and soul?

SPEAKER_01 1:02:48

Oh, my list is so happy and long. Um, I am completely obsessed with the show Heated Rivalry right now. Um, beautiful, queer story of love without punishment. And it is so beautifully acted. And I just I've never been one of these people who becomes a super fan and like goes super deep, but I have such a nerd about it. So that has brought me an enormous amount of joy and reading all about it and reading the interesting queer theory articles on it and stuff and feminist articles. Um I love reading romance and I love reading fantasy. I love going for walks with my closest girlfriends as I am a dyadic extrovert, a term that I completely made up, meaning I'd recharge in pairs of two. Um I love going on date nights and eating at beautiful restaurants with my husband, with whom I just celebrated our 30th Valentine's Day, which feels Oh wow. Um, I love family travel. Um, I like to lift weights. I've really, really gotten into being strong and having that be uh a positive way of walking the talk. Um and I love cooking and I love just curling up and doing nothing and allowing whatever happens to happen.

SPEAKER_02 1:04:17

You know what I want to say about that? There's a lot of things to love. Yeah. You know what I mean?

unknown 1:04:22

Yeah.

SPEAKER_02 1:04:23

And look, I love you. Thank you for being here. Um, thank the listeners. I know you got a lot out of this. If you enjoyed this show, if you want to hear more, click on subscribe and join this journey about becoming recovered body and soul. See you next time. Thank you so much for listening. I know how difficult and scary it is to understand, treat, and recover from eating disorder and body image issues. And I'm here because becoming recovered is possible and worth it. And I know that hearing from others has been there to help. So if you like this episode, please subscribe to the podcast where you'll receive updates regarding future conversations on becoming recovered body and soul. And if you're interested in working with an eating disorder recovery coach or training, become one.com where you're going to find information about coaching. Take good care of your body and soul, and I'll see you next time.