In Depth with former Helpline Manager Juliette Thomson on Person-Centred Recovery
This episode will be available on Wednesday August 2nd, 2023.
According to the Diagnostic and Statistical Manual of Mental Disorders, the DSM-V–also known as the psychiatrist’s bible–there are only four official diagnoses for eating disorders. Though experts expect that number to double in the next edition, the reasons someone might develop or maintain an eating disorder are as variable as the number of people affected.
This is because eating disorders are not just a set of behaviours. They are a way of coping with difficult things.
Psychologist and former Butterfly Helpline Manager, Juliette Thomson, specialises in a person-centred, holistic approach to recovery. “An eating disorder is often the tip of an iceberg,” she says, “Underneath, there is likely a lot more going on for a person about themselves in their lives.”
To help someone struggling with an eating disorder, a therapist will seek to understand their psychological and social reality. That’s why there shouldn’t be a one-size-fits-all approach; people need treatment plans tailored to their own situation. In addition, insists Juliette, you don’t need to be certain that you even want to recover, as a good therapist should support you wherever you’re at.
Listen to Juliette explain why she tells clients that recovery may be the hardest thing they’ll ever do in their life, and why it will also be the most rewarding.
Juliette Thomson 00:09
Eating disorders don’t just happen alone. They happen with other diagnoses as well as big questions of self esteem self worth. Who am I in this world? Am I safe to be in this world? These bigger questions are actually what’s often underneath what’s going on.
Sam Ikin 00:24
According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, the DSM five, also known as the Psychiatrists Bible, there are only four official diagnoses for eating disorders. Lots of experts expect that to double in the next edition, but the reasons that someone might develop or maintain an eating disorder are it’s variable as the number of people who are affected. They’re not just a set of behaviours, they’re a way of coping with difficult things. So to treat and care for someone who’s affected, we need to understand the underlying psychological and social reality, not just their symptoms, because those symptoms won’t go away without understanding and addressing what’s underneath. With all of that in mind, treatment can be as nuanced as those seeking care. And today’s guest should know. She’s Juliette Thomson, who ably managed the Butterfly National Helpline for many years.
Juliette Thomson 01:19
I am a psychologist who has been working in the area of eating disorders for over 12 years now. And I, in my private practice, I mainly see people who are struggling with body image and eating disorders. I also am a women’s empowerment coach, as well. So I think that also influences my perspective. And who I am really in my work.
Sam Ikin 01:47
What are some of the biggest myths or misconceptions that you know about when you’re talking about eating disorders?
Juliette Thomson 01:53
Yes, so I guess the the context that I see is when people come to treatment, they can really be very unsure about what their eating disorder is all about, and how it’s going to be treated in a clinical setting. And I guess the biggest thing that strikes me, and that I’d love for people to understand is that an eating disorder is often the tip of an iceberg, and the eating disorder behaviours and thoughts. That tip that’s pointing out of the ocean or the the water. And underneath, there is a whole lot more going on likely for that person about them in their lives. And we do, in treatment, have to look at the behaviours and target those, but actually, what we end up talking about so often is all the other stuff about life about them in life, etc.
Sam Ikin 02:53
Something that’s come up a lot through the course of the last, you know, three or four years that we’ve been doing this podcast is that eating disorders hardly ever exist on their own. So there’s always co occurring mental conditions or disorders, I suppose. It’s very seldom that somebody is only suffering of an eating disorder. Is that is that your experience?
Juliette Thomson 03:11
That’s right. I mean, once again, we can look at it as comorbidities, absolutely. And other ways that that in a world is presenting, but underneath all diagnoses, there, there are deeper questions about what’s going on with that person. And often diagnoses are the expression. And I’m not talking about 100% of the time here, I’m talking broadly. So yes, they, eating disorders don’t just happen alone. They happen with other diagnosis as well as big questions of self esteem, self worth, who am I in this world? Am I safe to be in this world? These bigger questions are actually what’s often underneath what’s going on.
Sam Ikin 03:52
And this is why psychologists are so importantly, in this treatment, we talk about seeing dieticians, and we talk about seeing your GP and keeping all of these other people in the loop. How how big a role is that if the psychologist.
Juliette Thomson 04:05
With eating disorders, we need to be often a part of a team, it depends on the individual presentation of the person. And this is something I really want to share as well. This idea of we have to meet and treat the person as they individually are so often people will need with a significant eating disorder, they will need a treatment team and a psychologist is a part of that team. T hat team approach is really important. There is some times where eating disorders show up where it may be a team approach isn’t necessary or isn’t possible for that person. And that’s actually okay to within boundaries. So yeah, team approach can be really important. And a psychologist is an important part of that team to do that uncovering work and that targeting work around behaviours and change and getting to the bottom of what’s really going on. But I also want to make point that if if you don’t do one to access other people, or your eating disorder is not in a very critical or intense phase, then it’s not always 100%. necessary.
Sam Ikin 05:19
So what happens, though, like, in terms of when when you do start working with somebody with an eating disorder. How does that treatment usually work? And I guess that’s a simplistic kind of a question, because you just said that every person different, right, but in general, are there some basic guidelines you can give us about how it works?
Juliette Thomson 05:37
Absolutely. I mean, from my perspective, the first thing to understand is that not only are treatments styles different, you could there’s actually a few different ways of treating an eating disorder, every therapist is going to be different as well. Okay, so you’ve got those two things to start with. And we want to as therapists look at a client as a whole person and work out pretty quickly what therapy style is going to suit that person’s needs the best, and what’s going to fit in that therapeutic relationship. So what I’m talking about is sometimes a therapist might say, okay, CBT E approach is going to fit the situation nicely because of A, B, and C. And sometimes that’s really inappropriate. A client may have gone through CBT E, a couple times on and had a good or bad experience, but it’s no longer appropriate. And you might want to move to a different model, depending on the eating sort of presentation.
Sam Ikin 06:35
I’m going to jump in and explain a couple of these terms as Juliet talks about them. CBT E is cognitive behavioural therapy for eating disorders, it focuses on identifying and challenging negative emotions, thought patterns and behaviours, and developing healthier coping strategies so that an individual can create a more positive relationship with food and with themselves.
Juliette Thomson 06:57
For instance, specialists supportive clinical management is another great intervention.
Sam Ikin 07:03
Unlike CBT e specialists supportive clinical management involves a person with an eating disorder working closely with a trained professional. The therapist can help them set achievable goals while also providing emotional understanding and guidance for managing those symptoms.
Juliette Thomson 07:19
So it really varies about what intervention you’re going to be using, and once you’ve isolated that intervention, you then you don’t need to follow the framework of that intervention. But it can look quite different depending on what model you use.
Sam Ikin 07:34
When you talk about the whole of person or holistic approach. What do you mean in terms of eating disorders?
Juliette Thomson 07:41
A part of that can be back to what you were talking about earlier with the team approach, having dietetics and medication as a part of understanding the whole person. The way that I view, a holistic approach in my work is this idea of, okay, this person, is showing up in the world, it’s not just the eating disorder. What is going on for them in the way that they live their entire lives? And what’s not working in that? And how can we understand the eating disorder within the context of the person as a whole? So sometimes people will say to me, oh, well, you know, I know we’re here to talk about the eating disorder in the early stages, but blah, blah, blah, blah, and I’ll say, oh, no, actually, we need to be talking about everything. If this other thing is important to you. 100%, it relates back to the eating disorder. Right? So in talking about someone’s whole life is important.
Sam Ikin 08:41
When we also talk about person centred treatment, can that can that exist within a holistic kind of approach?
Juliette Thomson 08:49
Absolutely, I think it is very important to take a holistic, person centred approach, because what you’re what you’re saying when you say person centred and holistic, the opposite to that is a manualized approach that takes no deviation or no account about the person sitting in front of you. And it and it does that therapy to the person without regards to to anything that they might be presenting that deviating from what’s in the manual. Okay, so that that is the opposite to a holistic person centred approach, because you’re not looking at the person in front of you and amending the model to suit that person. And you’re not looking at other parts of their lives necessarily if the model doesn’t account for it. So we love models. We love evidence base that’s so important for the treatment of eating disorders. We absolutely have to start there. But to to really work with somebody you know, in a powerful, meaningful and long lost why we really do need to add in the person centred approach and the holistic approach, in my opinion.
Sam Ikin 10:06
Everybody’s come on a different journey to end up where they are. So and this is something that I think we should probably think about in all areas of life, like, you know, you’ve always got to remember that people have gone a completely different way. Which is something I like to say to my friends in the fitness industry as well. They’re like, come on, I did it you can do that this guy did. It’s like, well, that’s great for them. That obviously worked for them. But there are a whole swath of people who for whom that won’t work, what areas of personal development? Is it that you would target when you’re dealing with a patient with an eating disorder?
Juliette Thomson 10:39
Critical areas that I find show up for many people, not all people are things like self worth, and whether that sense of worth is internally derived, or externally derived. Things like boundaries, and this actually is linked to self worth. But how easily can a person or how hard is it for a person to put boundaries in how do they understand boundaries. This idea of people pleasing, self confidence, generally, embodiment is another huge develop an area for someone, often with an eating disorder, and what I mean by embodiment, is showing up in your body in a safe way, not in a disconnected, fearful way. So these are some of the areas that I find, are absolutely fundamental to look at when treating and eating sort of, because if you, if you treat the if you target and traits, surface behaviours, and thoughts only and leave it there, then these, these concepts will be continued to be stuck and unhelpful. And they’ll continue to influence the person that in a way that makes it more likely for them to relapse or meet needs in another different, unhealthy, unhelpful way. So unless we get to the, to these core concepts, and sometimes it’s other core concepts, it’s a, it’s not a great chance in, in really making sure recovery can can stick. And I just want to make the point that it is okay for a person to just want to go in and target behaviours and thoughts, if that’s where they’re at, and they don’t want to do this work, that’s fine. There’s a lot of value in that. But in my experience, I really do explain to clients that this stuff is important to make it last.
Sam Ikin 12:34
I really love this whole area that we’re talking about with these particular areas of personal development, I think a lot of people are going to relate to these kinds of things. Tell us why these might result in the behaviours that would lead someone to an eating disorder?
Juliette Thomson 12:50
Absolutely. So if you feel that you are not worthy, and that’s a really interesting concept to unpack in therapy and what it takes, it takes a while because it’s a gnarly one. But I think most people understand this broad sense of of worth, at least when we first talk about it. If you feel that you are not good enough, and you need to work or attain or strive to be enough, then an eating disorder can come in and say to somebody, oh, I’ll help you achieve that. I’ll help you achieve to be enough in the ways of physical appearance that in a way that society may have historically supported, but also a sense of maybe control and achievement, right? You might define yourself as enough and worthy if you’re someone who’s, you know, self disciplined, and that’s the sense that some people have and when they first come to treatment, they say, I feel like I’ve achieved something when I use my eating disorder, and that’s making me feel worthy. Makes sense?
Sam Ikin 13:58
Yeah, absolutely, it does. Is it related to shame because we know shame is another driving emotion for eating disorders.
Juliette Thomson 14:06
It is fundamentally linked to shame. Shame is one of the most powerful core emotions that humans can have. And the reasons why people carry shame can be very different. But shame is absolutely linked to self concepts. And the the idea of the right to show up as you are completely without having to amend yourself or be in regret or feel that there is a part of you, that is not okay, and that you need to hide, right. These are all really, really cool concepts.
Sam Ikin 14:47
So when we’re talking about the relationship between the issues that we’re just talking about, and the higher incidence of eating disorders among women, and we know that we’re certainly not saying that there’s not a lot of men who do get eating disorders, but it is generally saying is something that he’s and the results show that there’s more women are affected. And that could be because men simply don’t want to ask for help, you know, a lot of reasons. From your point of view as someone who works with women and helping women to understand a little bit more about themselves. Why do you think that is?
Juliette Thomson 15:17
I think you’re absolutely right. There’s a whole lot more men out there who are experiencing eating disorders that may look a little bit different to the way that it presents for women, perhaps. And that’s a part of the reason why it’s being undetected. But it’s also socially not as accepted, I think, generally, for a man to identify and come forward with this idea of I have an eating disorder. So there’s a lot of complexity there. That’s the first thing I want to say. But yes, even when we take account for the underreporting, and our poor understanding of eating disorders in men, even when we can’t take into account for that, my feeling is that women, particularly for the anorexia, and bulimia categories are more represented in those behaviours and that experience than men. And I can’t give you the research on this in terms of the history and socio cultural impacts, because I haven’t done it. But my feeling as someone passionate in this space is that we like to forget about the hundreds and hundreds and hundreds and hundreds of years prior to this moment, where it has been explicitly said that women are property that women are not equal to men in any way. And we could talk for hours about the history of women. This is all factual, you know, there’s nothing outrageous here. But in our modern era is particularly in perhaps, you know, where we’re from in Australia, we, we forget that this history is behind us and continues to impact our psyche, on a really deep level.
Sam Ikin 17:04
When we look back at history with an understanding of women as property, often dependent on the goodwill of a man, do you think that these circumstances might have led to more of what you’ve been talking about before, including body image issues and eating concerns?
Juliette Thomson 17:20
I think that we’ll never, ever know, because women’s experience, everyday women’s experience weren’t well recorded, particularly about how they felt about their bodies and food. So I want to add to that in a little bit of her sitting on the fence way. But I feel that yes, it is absolutely possible that there was a whole lot more body image and eating issues that we will never scratch the surface of because it simply was never recorded in any way. The second part, though, is that I think that what we’re seeing today is a culmination of our history as women, a culmination of those ideas, and the revolutions that we’ve had as well. But when we look at social media, when we look at the way that capitalist modern society works, it is based off this idea that you are not enough. And if you buy this product, you will be enough. And you need to look as as attractive as possible, because that is very important in this society. And that hasn’t happened in a vacuum that has had hundreds of years behind it, influencing it. So I think it’s possible that genuinely, we have more eating disorders. Now, because of that combination of factors.
Sam Ikin 18:40
That makes a lot of sense. What we talk a lot about is finding recovery, telling me about recovery. It’s not an easy part, it’s not something that is just a straight road down the garden that you could map really is it this is something that’s far more complicated. Why is it such a big deal?
Juliette Thomson 18:57
Look, this is a bit of a spoiler alert, but I often say to my clients that recovery is probably not always but probably going to be the hardest thing you ever do in your life. But it will be the most rewarding, and it will be the most worthwhile thing that you have ever done, because it takes your life to a whole new level. So I think that sets the groundwork for the answer that yes, it is enormously complex recovery. You can do recovery as far as you want as an individual. And recovery is a very personal concept. One person’s recovery is not another person’s recovery. Sure, we can look at the DSM and say, Well, what what’s the criteria for an eating disorder? And does this person meet that criteria? And through treatment, we hope that at least that person will no longer meet those criteria. But there is a whole lot more recovery than that criteria. Someone can be still actually struggling with an eating disorder. disordered eating and not made that recovery. But it is complex exactly because of what I have been chattering on about this whole interview. And that is because we’re looking at a whole person and their whole life. It is not just about resolving these target behaviours, right or symptoms, it’s saying, Who do you think you are as a person? And how do you want to show up in the world. And that takes time, because by the time someone gets to the therapists room, they’ve had, if they’re an adult, 20,30, 40, 50 years of, let’s call it, programming or way of ways of living, that have built and compounded. And it takes time to unravel that, if you think about an archaeological dig, and the strata the layers, right, that’s how I like to look at a person, there’s many layers, there’s a lot of things going on. And that takes time to unravel. And because it is quite intensive and exhausting, that there needs to be space for that a person may want to have more intense therapy, then back off for a little while, and then come back and have more more intense therapy. I mean, each person’s journey looks different, but it is potentially a big process.
Sam Ikin 21:18
If someone can’t access direct support for someone like you, what kind of advice would you have for somebody who really needs it?
Juliette Thomson 21:26
One thing that’s really important for people to know is that you do not have to be 100% certain that you want recovery, and that you can do recovery before you reach out to a therapist. A therapist should be able to support you where you are at. So I really encourage people if they’re thinking about therapy, first of all, to to jump in wherever they’re at and go to the therapist, the therapist and say, you know, a part of me doesn’t want to recover at all. And a part of me does, right. So that’s the first bit of advice I want to give. The second is that there are some great resources out there; books, online resources that can get you started on this process. One that I think that is really accessible in so many different ways, is Carolyn Costin’s Eight Keys to Recovery. It is a nice starting place, it’s definitely not going to be probably the book that solves everything for you. And you can say I’ve recovered afterward. But it can be a nice way to start thinking about some of these concepts that we’ve been talking about. And there are some great resources that you can access, I’m sure through the big organisations like the butterfly foundation to get that ball rolling.
Sam Ikin 22:42
We’ll put a lot of these links in the show notes. Don’t feel like you need to be taking notes while you’re listening to this podcast. But Carolyn Costin was one of the first people we interviewed for this, this this project. And that’s an amazing book. So Juliette Thomson, thank you so much for your time. How can people find you and where can they maybe you know, hear about some of your work.
Juliette Thomson 23:01
Great. So I have a clinical website. So that’s juliettethomson.com. And that’s where I do my clinical psychology work. As I said, I’m also a women’s empowerment coach and I have a podcast myself called The Sisterhood Downloads with with a wonderful friend and psychotherapist Jacqueline Burn. So if people go to their podcast provider and type in The Sisterhood Downloads, you’ll find it. We spend a lot of time talking about these big picture concepts, particularly as it relates to women or people who identify as women.
Sam Ikin 23:34
Amazing. All right. Well, thank you, Juliette. Appreciate it. We’ll make sure we have all of those links available to everyone. But thanks for your time. Lovely to talk to you. That’s holistic recovery expert Juliette Thomson. And if you think that you or someone that you know could benefit from being in touch with someone like Juliette, Butterfly has a referral database on their website. It’s a directory of professionals screened for an understanding of eating disorders so that people Australia wide can get help recovering or caring for someone with an eating disorder by finding the professionals that they need. If you need help or support right now, there’s the Butterfly Helpline on 1 800 33 46 73 That’s 1 800 ED HOPE. That’s the number to call for free and confidential support from 8am until midnight, seven days a week. I’d also urge you to look up Wandi Nerida, which is a safe nurturing healing space for eating disorder recovery. It’s currently Australia’s only specialist residential eating disorder recovery centre, which uses a model of care based on Carolyn Costin’s book The Eight Keys to Recovery from an eating disorder which Juliet spoke about during our interview. To find out more, we’ll have a link to that in the show notes as well. Butterfly: Let’s Talk in depth is produced by Ikin Media in partnership with Butterfly Foundation with the support of Waratah Education Foundation. I’m Sam Ikin, your host producer and editor. Our executive producer is Camilla Becket. And as always, if you want to support this show, please just drop us a message or a rating in the app that you’re using right now to listen to this podcast. I’m Sam, Ikin, thank you so much for your company.