[DR. CRISTINA CASTAGNINI] Behind The Bite podcast is part of a network of podcasts that are good for the world. Check out podcasts like the Full of Shift podcast, After the First Marriage podcast and Eating Recovery Academy over at practiceofthepractice.com/network. Welcome to Behind The Bite podcast. This podcast is about the real-life struggles women face with food, body image and weight. We're here to help you inspire and create better healthier lives. Welcome. Well, hello everyone. You know it's interesting, I'm a psychologist and yes, I understand I'm an eating disorder specialist, but somehow, I find that I get so many questions about exercise, whether it be when I'm in my office or not in my office. It can be one of the most difficult topics to tackle. I think it's because we're all encouraged to exercise to be "healthy" and it's hard to know how much, how often or even what form of exercise to do. There can be a line that gets crossed when someone has an even disorder, because it becomes part of the illness, which is anything but healthy. I can share personally, I crossed that line myself when I had my eating disorder. So I know that line that can get crossed and I know it can be very confusing. So I am sure excited for our guest today to come in and help us make some sense out of all of this. Amy Gardner is a certified eating disorder registered dietician and yoga teacher from Boston. Amy combines over 20 years of clinical and personal recovery experience with psychology, mindfulness, sensory motor, and yoga training to help her clients move into full recovery. She's owner of Metrowest Nutrition, a multidisciplinary group practice, where she's supervises other eating disorder clinicians, and author of the book iMove, Helping Your Clients Heal from Compulsive Exercise. Through the iMove program based on her book, Amy leads movement groups and trains other clinicians, how to use the iMove method in their own work. All right, Amy, welcome to the show. [AMY GARDNER] Thank you. I'm happy to be here. [DR. CRISTINA] So this is a topic that I think a lot of eating disorder clinicians maybe don't talk enough about and for probably good reason because I think it's a question of like, who actually takes it on. So I'm actually curious would you mind sharing us with a little bit about how you actually got interested in, I guess looking more into this and how you got into space of specializing more in, I guess, I don't know if it's specializing in more, but like being at the place you're at, in your career now where this is something where I'm having you on the podcast to talk about this? [AMY] Yes, absolutely. So it's a combination of my own personal recovery experience and the work I've done with people over course of over 20 years now in their own eating disorder recovery, just seeing how significant the role of compulsive exercise can be and watching that have a pretty substantial impact on people's recovery trajectory. It was one of those things that I felt like it was the precursor to people relapsing when they'd come out of treatment programs. It was like the exercise wouldn't have been addressed. So then they start exercising and it's like a snowball effect into back into behavioral patterns. I know for myself using movement or finding a different relationship with movement was really valuable and helpful for me in my recovery process. The reason why I wanted to create this program was really to help others be able to transform their relationship with movement so that it's something that's more helpful and beneficial in the recovery process so that it's not labeled as this all or nothing like, oh, exercise is a behavior or not and if you're not abstaining, then you're aligned with recovery when in fact I think going into the movement can help us go into our bodies, which is something that's a really important part of the recovery process. [DR. CRISTINA] I think there's, what I find is because there's, in our diet culture, anyways, diet and exercise, it's always like eat less exercise more. There's always this tied relationship. So it's one and the same and so I think it's how to overcome that hurdle and tease out like food and what you eat is not necessarily tied to how much movement or how much exercise you're doing. I don't know how we as a society stop tying the two together, but I think, I don't know if you think that that's part of the problem and why it's so difficult to, in recovery or in treatment to not have movement or exercise be this thing people don't want to touch or don't know even how to incorporate into recovery your treatment. [AMY] Absolutely. I think it is very much tied into the dominant diet culture messaging. We get a lot of messages that more is better and that the, think about no pain, no gain, and some of this mentality that people have around exercise and what constitutes exercise and what doesn't count or what qualifies and quantifies as exercise and what the purpose of exercise is. I think it's always, it seems to be oriented around like you said, tying it to some energy expenditure or the amount of food one eats, and it's always connected to changing the shape of the body or size, et cetera; whereas there's a we're really intended to move as human beings and there's a value to movement much like that extends beyond that. I think movement can get very disconnected when we've got all these external ways of measuring it, whether it's like Fitbit or an iWatch, or you're seeing your friend statistics on some an app. And it becomes much more of an externally driven thing versus something that's a way, something, that's a source of connection to our own body and therefore is driven by our own natural impulses to move. [DR. CRISTINA] For you it sounds like you have this, your own history of having maybe a dysfunctional relationship with exercise. Did you know at the time that it was dysfunctional or was that something that you learned or realized along the way in your recovery? [AMY] No, in fact, it wasn't, it's interesting to think, look back, it was never addressed. I never addressed it. I never knew it was a problem. I was an athlete. It always was very, to me, like normal to be exercising a lot, and I could always justify it in with that athletic identity. I think that there was some, there was definitely crossover there, like between this eating disorder, identity and athletic identity that I wasn't always clear about at the time. We were focused so much on I think what I was identifying as the behaviors that I wanted to address and the exercise was something that was not, I didn't want, maybe I didn't want to bring into the realm with my team and at the time in this, we're now talking like my gosh, crazy, 30 years ago. Things were much different and I think maybe exercise was thought of as still, I mean, it always still is thought of as something very beneficial to health and helpful. I don't necessarily blame my treatment team for not addressing it, but it wasn't something on the radar. It wasn't something that was actively being discussed or there was a lot of concern about. I think as long as my labs were normal, et cetera, there was no reason for concern and I never had any kind limitations placed on my exercise, but likewise, it wasn't really discussed either. Looking at that I realized it was a big part of the picture absolutely. [DR. CRISTINA] I have a history myself and I never realized that exercise was my way of purging at all. I thought, oh, this is me being super healthy and taking care of my body and doing all the things I had in the magazines. [AMY] Yes, exactly. There was a number of other eating disorder behaviors that you might have classified as like not healthy or what I would call like, ego, dystonic things that don't feel good or may have some shame associated with them. But that one felt really good and positive and it was helping. I always felt like I was aligning more with that athletic identity that felt like a good identity whereas the eating disorder identity, as I was engaged in recovery, at least it felt bad. I didn't like the part I wanted to move away from. So I think the exercise also in my mind was a way that would have helped me feel stronger. I mean, it had a lot of, and that's not a bad thing, I think that that's one thing I talk about a lot in my groups with clients and individually in session is that there's a lot of ways that movement and exercise really help us. It provides something and is life enhancing. Then we just have to be able to find a way to relate to it, where it is providing us with benefit versus taking away from our lives. [DR. CRISTINA] That's well said, because I don't know how you felt, but I felt like all, some of the eating disorder behaviors I was so ashamed of and wanted to hide, this was one where I didn't realize, first of all, it was eating disorder, but I got a lot of praise and a lot of like, oh my gosh, you're so healthy. It was my identity. I felt like, oh, I'm such a good athlete and I'm getting trophies and all this great stuff. This is the one thing where I could do it and shine. It was fantastic. I'm not going to get rid of this. [AMY] No, that's a good point. There's a lot of positive reinforcement for this type of behavior, for exercising a lot. I actually think it's funny that you say that. I actually remember in college in a sorority and I remember one of, I was a nutrition major and there was a senior graduating. I think I was in a sophomore. She was like, I always look at you and think of you as like the ideal nutrition student, because you've always got your water bottle and you're always running and I'm thinking if you only knew. But yes, that's the picture that's painted for us, like of what is ideal health or what is what is virtuous when it comes to behaviors? Meanwhile, I mean, that just made me feel like crap because then knew underneath. There was all this other stuff going on and all these thoughts and feelings I was having about my body and working through in therapy. So it's just interesting that there can be such a disconnect between what people are seeing on the outside and what's probably being shared quite honestly, on social media and what's actually happening underneath. It's been quite interesting to see people outwardly on, just thinking of a friend of mine who, well, not a close friend, but acquaintance who was out on social media and she was going through this weight loss journey and she was sharing a lot about her process very publicly. Then at one point, and I was just like, I saw it coming. I saw like, oh no, this is not going to be good. She reached out to me and expressed and she said, "I'm so thankful that you've been posting all these things you're posting because I'm really struggling. I feel like I went through this process and it's been really hard because I'm not realizing that I developed an eating disorder as a result of all these behaviors I was engaging in." So it was really interesting to see that because outwardly, like this was never public. This was all, she messaged me on the side but to see what she was putting out there and people seeing, oh, she looks happier, she looks she's healthier. Yet meanwhile, underneath that, there was this other experience that she was having and one that she didn't want to put out publicly. So I think that's always important for people to know is there's another side to the story and there's potentially something else going on underneath. People don't necessarily publicly share what might feel more shameful or the darker shadow side of all of this. [DR. CRISTINA] Yes, so let's talk about that side, because I think people maybe listening don't know that. They're like, wow, I just see people that on social media look like they're so happy and I wish I had that motivation. I wish I could do that. What's the darker side? What does that look like? [AMY] It looks like really being consumed by thoughts about food, thoughts about exercise when you're going to exercise, feeling unbelievably guilty and anxious when you don't get exercise and feeling like there's a lot lack of interest or loss of interest in things you might normally have or prior to this been interested in, feeling out of control. So oftentimes when there's been an energy deficit for long enough, or I say oftentimes pretty much always when there's been an energy deficit for long enough, there's going to be a psychological drive to eat more. So a lot of times what results is binging or loss of control around food, which can be very upsetting to someone who has been working so hard and focusing so much on these diet aligned behaviors and trying to get to a certain place with their body. So I think it's, there's that other side of this experience for pretty much everyone that goes through a diet or any significant weight loss endeavor that comes with it. I think that no one's going to be posting that out there openly for people to see. Oftentimes I hear people share that they don't show others what's really going on. A lot of their time is spent maintaining this perfect façade and keeping, even though it's not real, I think that there's just this maybe a perception or belief that as long as everyone else thinks everything's okay that it will be. Yes, so it's a very lonely experience. [DR. CRISTINA] Yes, a lot of isolating, a lot of alone time to fit this all in and to not feel the guilt of not doing it. It would seem whatever people are putting out there, it seems like they have this great life and everything is fantastic, but a lot of loneliness, like you said. [AMY] Absolutely. [DR. CRISTINA] So if somebody maybe is listening and they're saying, okay, I can relate to everything you're saying about the dark side, I feel guilty when I don't exercise, I spend a lot of my day trying to fit it in, just all the things you mentioned, if somebody were to come see you, how would you start working with them to start shifting their relationship with exercise and movements so that when those awful feelings of guilt or fear of not working out or keeping up this pace with their exercise regimen, how would you start working with them so that it starts to shift? [AMY] That's a good question. Initially, we want to spend a lot of time unpacking the issue and really understanding its origin. I'd want to get some help, someone explore that, like their history with movement, with exercise, the thoughts that come up around it, really understand what rest feels like for them, what their perception of rest is and what their perception of movement is. So I like to actually ask people what their definition of exercise is and what their definition of movement is and if there's a difference there. In really getting into what it's like to take a day off, talking a lot about what they enjoy about the exercise, what it's offering them, what it's giving them and what feels like it's how it's taking away from their life. We get into, we do a lot of values work initially, where we're really getting familiar with what this individual's values are and how their relationship to exercises either are helping them align more with those values or moving them more out of alignment with their values. That's setting the stage for any future work we do. We're always going to come back to that and remember that we're working towards creating more meaningful life and putting exercise in its place in their life so that it's helping them. It's helping and maintaining those ways. It might feel like it's helping them, but not, but hopefully removing or limiting the ways. It's not helping and providing alternative coping strategies and ways to help regulate the nervous system. It's a big part of the work of the iMove program that we do in the group setting, is to help find alternative ways to regulate the nervous system because it's oftentimes the case that someone feels strong impulses to move when they are sympathetically activated? [DR. CRISTINA] You mentioned the iMove program. For people listening, can you describe a little bit about how you came up with the iMove program and more about what it is because it's a great program? [AMY] Yes, absolutely. Actually the idea came out of, honestly, I was going through yoga teacher training and I was in Shavasana and I just was really feeling grateful about where I was in relationship to movement in my body and just had a moment to reflect on how I got there and realized like there was all this wisdom I hadn't really been sharing with clients and was feeling a little bit challenged with how do I present this? How do I give it to people? So then I started really working through, coming up with ideas and thoughts and writing and putting the program together. It really, so basically, it's broken down into three sections where we spend time exploring the issue and the relationship with exercise and getting familiar with values. Once we've completed or we've started explored the relationship with exercise, we move into a combination of education and experiential work. So I'm doing a lot of education on the nervous system, on mindfulness and the benefits of it, helping people get to know their sensory system and how all these things might play into their use of exercise and what exercise they're gravitating towards. We do a lot of experiential work around going into the body. So we'll do some breathing exercises, we'll do meditation, we'll try different kinds of group activities where we're incorporating elements of polytheory. So talking a lot about co-regulation versus self-regulation and bringing in some sensory activities, just giving them different experiences with alternate coping strategies and things they can bring in to help suit their systems at times when maybe they feel driven towards exercise and giving them a different experience with movement and helping them really slow down, which a number of them describe having a hard time doing right. Just giving them the experience of slowing down or the experience of being at rest and really being at rest and being in that experience, which in itself is a challenge. And we spend a lot of time processing it. So the group itself becomes a container in this holding space for anything that comes up. We create a lot of safety and it becomes really a nice a resource and community for individuals that are healing from compulsive exercise. It does extend me on compulsive exercise. It goes into other eating disorder behaviors too, in the sense that it, when I've surveyed participants, they indicate that there's a substantial improvement in all eating disorder behaviors. It's not just the exercise. I will say the exception to that rule is one person in particular that I have in the group now, who's going through EMDR and doing a lot of heavy trauma work, and then her symptoms have stayed around the same, exercise has improved a little bit, but I think what we've, but she's expressed that this group has been really valuable in supporting her and providing an additional support while she does that trauma work. But that's been the only exception I think to the role is. But most of the other individuals are really seeing a transition in their relationship to movement and one that's very welcome. In fact, they often find that they want to covet it and protect it and it feels like a very beneficial part of their self-care regimen. [DR. CRISTINA] I find that fascinating, so I'm now doing outpatient work and constantly am getting the questionnaire. I have people who come in and they're exercising hours a day and so even for me, the question is even if they come out from a higher level of care, the question's always, well, how much exercise should I be doing now and even when they're getting discharged, there's not really an answer. [AMY] Well, I will say there's a great resource and I can't take credit for this one, but it's amazing. I reference it all the time. It's the safe exercise at every stage. It was developed by some Australian therapists. It's an amazing resource and it has a whole grid that can guide you around where someone should be, or could safely be exercising, given different biometrics; so where their blood pressure, their heart rate are, where their behaviors are, where they are in terms of their nourishment, those types of things. It's actually a really helpful guide. I think I I've used it a number of times with clients just to show them like, there's actually some science behind this, and this is why we recommend this level of exercise at this point in your recovery and where would you like to be and how do we move you forward and simultaneously work on forming a different relationship with exercise than maybe you had prior to going into eating disorder treatment. Because I think that's the thing. If we're not really addressing it and eating disorder treatment, like higher level care for the most part, I think some programs do a nice job or starting to. But what happens is because we're spending so much time on the food and getting weight restored, if that needs to happen. Because the relationship with exercise hasn't really been addressed, it's like this outlier. It's like now what do I do with it? A lot of people leave treatment with oftentimes a lot of fear about incorporating exercise. Again, I think there's a fear that they're going to go back to where they were, but they may want to incorporate it and they just don't know how to do it. So this provides a nice roadmap for how to integrate exercise in a way that's much different and oriented from the body and listening in collaboration with the body, not something that's happening to the body. [DR. CRISTINA] Because I think it's almost like, I feel like we're playing past the potato. It's like clinicians maybe go, well, medical doctors need to address how much you can do. Medical doctors don't really know the guidelines so it's almost like who determines it because I know it's like me going, well, I don't know. I don't want to answer if you're not medically stable enough. So maybe I'll say your medical team needs to say how much exercise you can do because I don't want that really on me. They're the ones monitoring somebody's physiology and physical wellbeing. So, yes, that's scary but the like sometimes I feel like the medical doctors are saying, well, you're the clinician. It's just an eating disorder, treatment thing that maybe you should know. So I think there's a lot of, there's not a lot of discussion or knowledge, I guess, about who's really monitoring the exercise and saying what's appropriate, what's not. I don't know how you feel about that, but. [AMY] Yes, I do feel like that's one of the gaps. I think that's one of the issues and one of the reasons we're not addressing it more is because there's this uncertainty about whose role or whose domain it falls into. I a hundred percent agree that the doctor needs to establish the level of safety around exercise at different points in time. So it may be that the doctor says, no, we're not in a place where exercise is possible right now for X, Y, and Z. I would absolutely support that. But when we're talking about when someone's able to start incorporating exercise again, or they want to that's when I think they need help navigating it. That's where my hope is this program comes in and it provides clinicians and clients with a model, they can use to help explore that relationship with movement and start to help the person shift from, again, that external locus of control to internal. The way we want to deal with eating, like we talk about intuitive eating and moving into sensing the body's cues and this interceptive awareness that we want to develop. It's the same thing around movement, like, all right, you're having this urge to move. Where is that coming from? Let's explore that a little bit. What movement are you wanting? What are you looking to accomplish with the movement and then observing what happens. Okay, you wanted this, you went for a run, how did you feel after? So helping people reflect on what they're looking for from the movement and what it's actually providing them and also giving them alternatives when they really don't want to be moving. Like they may feel like the only way they can regulate their system is to exercise, but the program gives them alternative options so that when exercise either isn't accessible or they're preferring, they prefer to try something different they have those things available to them. [DR. CRISTINA] How much do you address, like, I guess the ED thoughts related to exercise, like, oh, if I don't exercise, I don't earn my food or I only get to eat if I exercise X amount or I can only start my day once I exercise this amount or these rules related to exercise? [AMY] So you were talking about when people have a lot of these thoughts and rules around exercise and what I might suggest. I think that is where, I mean, some old school, like CBT comes in, working on the thoughts in any way we would work on other thoughts, relating to behaviors and really challenging those rules and the beliefs around exercise. A lot of it does quite honestly come from information picked up in our culture, in the media and from friends and family, et cetera. So I do like to explore where are you getting these messages and what impact are those messages having on you and really talking about the emotional impact and helping them see that it is a choice whether, like there's a choice in their relationship with movement. One of the things I think's been really helpful for a number of people in the program is they get it on more of a visceral level, like on some level before they believe that, oh yes, I have a choice whether or not to exercise, but I'm going to exercise because it makes me feel better. It helps me stop thinking about it so I can just get it out of the way and move on. What they realize is just by slowing down and having a different experience with movement, getting into their body and and building up a window tolerance for that they actually really feel on a visceral level like, oh no, it is really my choice. I don't have to move in a compulsive pattern in order to get myself to baseline or to whatever, fill in the gap there, to get rid of these racing thoughts, obsessive thoughts about needing to move or needing to do these things. It's finding and recognizing that sometimes when those thoughts are racing and more active, that, like any things around food, there's something else going on. If you can drop down into the body, a lot of times, there's a deeper wisdom that you can access there. Some people have even identified that by not exercising compulsively, they've been able to make a lot more progress emotionally in their recovery, because they're able to, and to feel a sense of power in being able to hold an emotional experience and work through it whereas if you're moving really fast, you're moving away from the problem, so to speak and not necessarily sitting with it and letting it on a natural way. [DR. CRISTINA] You've been doing the iMove a program for how long now? [AMY] In just under two years. I really started the pilot and it was so successful. I started simultaneously writing about it, just writing it down, then I wrote the book and now, the first group of participants, I still have two people in this ongoing group. So they've continued for, like, we do three months segments and they've just continued. We're taking a break for the first time. They've actually established like a peer support Lister where they're staying connected over the summer and reading books and we created some guidelines for that to create some safety so that it was being used for therapeutic purposes and not as personal. It's been just great to see the connections that they've formed. I'm going to try doing it virtually this fall. It'll be interesting to see if it translates the same way. I've done the clinician training I've done virtually and that works really well but I'm curious to see if I can effectively lead a client-based group virtually in because a lot of it does depend on this co-regulation and I feel like in space together, there's another layer of connection that we have. [DR. CRISTINA] That's fascinating. So two questions, one, if there's somebody out there who's saying, "Oh, this sounds great, I'd love to get involved with this," how long would, say from, if they started working with you, how long is it typically till you've seen progress in people going through the program? [AMY] I see progress like after the three months. When I survey people, there's always some progress at that point. I will say at the year point I'm thinking of a couple people in particular that were with me for a full year and they will honestly say their relationship with exercise is completely different than when they started. So I think that's a very individual thing, how long. I think it probably depends a lot on how long you've been engaging in the patterns, how ready you are to make change, how much work you've done prior. So there's a lot of variables in place. I will say for some individuals, if groups in general have been hard in the past or have been really challenging and they shut down, it can be better to do the work individually. Because I think going both going into the body and being in a group, if a group doesn't feel supportive to you for some reason, or sets your system up for more of defense mode, then it's probably going to be a hard space to do this work. But for folks that really value group and get a lot out of group and have struggled to go into their body and to build, have any level of tolerance for being in their embodied at all, this is a really great, it's a great model. For people, I think one of the reasons that people do compulsively exercise, I know because I've seen it in the group is to really escape the body and get out of the body and avoid. And this is giving them an alternative way of regulating, but being present and being with the body. [DR. CRISTINA] On the other side, so if clinicians are listening and they're saying, oh, how do I get trained in this to use it with my patients, how does that work? How do you train people? [AMY] I've done two pilot trainings for inaudible 00:35:37] really well. There'll be another training coming up in the fall. You can find all this information at imovemethod.com. That's where you'll find information about the training, the book, resources. It's in development now. I don't know when this podcast will come out. So at that point, it hopefully will be ready to go, but sometime and then in the very near future, all the details about the training will be up there and there's going to be a couple that will be a self-led and then the other one will be more like a full certification. So if you want to learn about the model and apply it to your own individual work, but you're not necessarily interested in leading iMove groups the best option would be the certification because that's a more of a 12-week program with some live calls and a lot of additional resources with lesson plans and group format and all that. [DR. CRISTINA] Fantastic. You gave the information for the website. People do want to learn more about you, find you, how can they do that? [AMY] You can reach me if you have questions, or I also have offered to give people some, the questions that I ask in an activity to dive deeper and explore the relationship with exercise. So I'm happy to offer that. You can just reach out to me at amy@metrowestnutrition.com, and I'm happy to provide that and answer any questions. [DR. CRISTINA] Very nice and generous of you. Thank you for that. Sure people will be taking you up on that. If you guys didn't get that information, it'll all be in the show notes as well. Any last words before we end, Amy? Really appreciate your time. You've given a lot of fantastic information, but I don't know if there's any last words before we end. [AMY] No, I just I think there, I encourage people to get familiar with ways to explore exercise with clients. Then for those of you who are people struggling with compulsive exercise, just know that there is a way to shift this and have a little more freedom around this area of your life. So there are definitely different options for different people in terms of what your readiness is and what your resources are. I also encourage anyone that's interested in potentially participating in the virtual iMove group to reach out to me as well. [DR. CRISTINA] Great. Well, thank you again so much. Head over to her website and like I said, all the information's on my website. [AMY] Thank you, Cristina. This has been great. I've enjoyed talking with you and I look forward to connecting in the future. [DR. CRISTINA] Actually I might head over to your website too, so thank you so much. [AMY] Awesome. Thank you so much. All right. Take care. [DR. CRISTINA] You too. This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, accounting, clinical, or any other professional information. If you want a professional, you should find one.