Doug Bunnell, chief clinical officer of Monte Nido and Affiliates, takes some time to discuss what he calls clinical wisdom – a vital component for any clinician treating eating disorders.
Doug’s book –
Full Transcript –
Kathy: Hello and welcome to ED Matters. This is Kathy Cortese, your host and today I’m welcoming Dr. Douglas Buneell. Doug Bunnell is a PhD psychologist, a fellow of the Academy of Eating Disorders and an expert clinician and leader in the eating disorder field. He brings over three decades of experience and a wealth of knowledge to his role as chief clinical officer at Monte Nido and Affiliates. A graduate of Yale University, Doug did his doctoral training at Northwestern University. He’s a former board chair of the National Eating Disorders Association, a fellow of the Academy for Eating Disorders, author and frequent presenter at National and International Conferences. He’s passionate about research and the latest advancements in the field and is equally committed to individual lives client care. Hi, Doug. How are you today?
Doug: Hi, Kathy. Thanks for inviting me to do this. It’s an exciting project and I’m looking forward to contributing.
Kathy: Thank you so much. We have a very interesting and I think kind of exciting topic that Doug has chosen to share with us today and that is the topic of developing clinical wisdom. So I’m curious what led you to suggest that we talk about this and how you might define it.
Doug: Well, part of it is because I’m getting older so I don’t feel like there’s some sort of wisdom I’m supposed to have accumulated by now and I sort of sense that I have that. I talk to my peers and we sort of have a short hand now for knowing what we’re doing clinically that I think didn’t develop consciously or that we sort of read in a book or was in a manual or was even in a research article and there’s some sort of accumulated experience that hopefully if married up to you know, commitment and hard work and intelligence, matures into some sort of wisdom and familiarity which maybe will help to define wisdom a little bit, at least I’m thinking about it. It’s some sort of amalgam of real knowledge, intelligence and foundation of science and training married with a willingness — it’s almost like a knowing willingness to not know to realize what you don’t know to be open to looking at things differently but without sort of going off the rails. And sort of staying true to some sort of theory or model that you know is grounded in fact but with increasing wisdom, we have increasing confidence that you can sort of move off that straight narrow and still feel like you’re moving in generally the right direction. So the question what got me interested in it and on personal issues because it all starts with our own personal issues but more so in my role as a chief clinical officer, I’m really charge now with looking at how we train and develop relatively young therapists coming out of graduate training and as quickly and efficiently as possible help them develop a little more wisdom and familiarity with a wide range of treatment approaches and treatment models. I think most of us in the field have seen that newer clinicians come into the field now with somewhat narrower skill set they might have had a decade ago.
They’re really good at that narrow skill set but they don’t necessarily come in with a wider appreciation for different aspects of psychiatry, different aspects of developmental psychology, different aspects of cultural diversity and gender issues and psychodynamics and the wide range. So that’s a long winded answer to what got me interested in it but I’m trying to think through how would we actually teach wisdom or how do we set up systems supervision and training and mentorship and actually facilitate that.
Kathy: Thank you. You know, when we take this now knowing that your area of concentration is eating disorders, you know, the first word that comes to mind is complexity and your definition of wisdom involves complexity and you’ve used the term marry, so could you marry those two? Eating disorder, clinical wisdom.
Doug: Absolutely. I think – as you mentioned in the intro I’ve been doing this for awhile and I’ve seen the pendulum swing back and forth in terms of approaches to treatment and approaches to conceptualization even of eating disorders and their etiology and their maintenance but what’s always intrigued me and probably the reason I’ve remained interested in the field for so long, is that it is so complex, that you really have to be fluent in a wide range of databases and knowledge bases and be able to have a presence and a charisma and a relational sort of set of talents or skills or whatever you call them, to engage people. And so if you – I say this to our clinicians all the time. If you’re not comfortable with ambiguity and complexity, this is not the field for you. If you need to see things move ahead in a nice linear fashion and that’s really what excites you, you’re going to be likely frustrated in this niche. So I think there is some language wisdom does encompass not just the comfort with ambiguity and openness to it, it’s like you seek it out like I want more, I want to come up with a model or a way of understanding what it’s like for you and your eating disorder. It involves not just – no I mean to be really basic, not just the thoughts and feelings about your weight, shape and body but what it means for you to be a man or a woman or what it means that you have this family experience, what it means that you want to be an artist. Because those things inevitably pass the point of actual symptom remission, my experience has been it’s those sorts of things that are going to really solidify someone in recovery. Unless you do — for most people help them do some exploration, sometimes some work and often times, some real healing in those dimensions. You’re leaving them at somewhat a heightened risk for slipping back into the behaviors.
Kathy: And exploration is such a useful term but sometimes misunderstood because there can be this scratching surface exploration and there can be the deepening and there can also be let’s call it the clinically wise exploration. Might you venture to sort of differentiate some of them?
Doug: Great question. I think about the continuum of therapists that I’ve worked with and trained and so forth. You do have that one extreme folks who are terrific at exploring but not so familiar or comfortable with actually facilitating change. Then you’ll have other folks who are really great at sort of driving people with setting up goals and objectives and working on sort of discreet, you know, meaningful behavioral change but they’re not clicking and they’re missing cues that happen in the relationship and they’re missing important opportunities to take some of the clinical examples and bring them into relationship and broaden their understanding of what that behavior might represent for that person. So those are the two polarized experience, most people always there in the middle. But we wanted as a field I think, want to be working to help clinicians be able to move across that continuum with some forethought like to have a sense of why at this moment or at this phase of treatment, you’re focusing more of behavior change but also being open to saying, okay, this point maybe it’s going to make sense to shift back into a more – I’m going to say more dynamically informed conceptualization of what’s going on and the simple “civil war” in our field between those who say do behavior therapy versus those who want to do something more eclectic or psychodynamic therapy, it’s just such a false dichotomy. I mean the vast majority of clinicians, even I’m going to venture to say across the world, across the world of eating disorders are doing integrated psychotherapy. There are so few therapists in my experience even here in New York City, sort of the heart of psychoanalytic theory and work and training, no one I know who’s working with people with eating disorders from a dynamic perspective is not also working with him from a behavior change even cog, you know, strictly straight up cognitive behavioral branch. But wisdom I think involves or is defined by the capacity to shift back and forth between those two poles knowingly. Not just because you feel like it, not just because, you know, that’s what I like to do or you have a thought in your head about, you know, why right now makes sense for us to be working this way and that’s wisdom.
Kathy: And you know, I think that speaks to your point about there is this foundation of science, this isn’t flying by the seat of one’s pants or the intuition to perhaps shift gears or go deeper but that knowledge base and the conceptualization one has, it can often lead a person but you also brought up the relational aspect and I think that that’s really, really, I’ll say rather essential when it comes to eating disorder therapy. Please.
Doug: I think all of us probably struggle with the definition of how do you actually train someone to be relational. I think you look at some of the relational, cultural therapists and they actually do have a model for training and sort of a set of skills or competencies. Again, this is sort of one of the things I say to my trainees or my new therapists, you know, if you’re going to succeed in eating disorders world, you’re going to have to become a real expert at engagement because you’re often almost always working with people who are ambivalent about what you’re offering them. And unless you can present a sense of or help develop and foster sense of curiosity and excitement and sort of a like “gosh, how are we going to figure out how this all hangs together,” and really get people turned on to that, I think we lose folks and if you go in too hard for the change without sort of doing some of the other work and trying to understand who the person is – do you [?] think we drive people at our treatment, you know, for all the – this may get me in trouble but for all the research we have on CBT and FBT as clearly the best supported empirical treatments, continue to have enormous dropout rates from these treatments. So they don’t work or not palatable or acceptable to a lot of people and I think we as a field, need to be wise enough to see that that’s a great foundation but something else is necessary and my experience at this point I think that something else involves this judicious, flexible, wise shifting in mixing of approaches. I tell my therapist all the time, people I work with and I’ve learned this from my colleagues and peers in the field too. If I’m sitting in session with a young woman with anorexia nervosa and we’re talking about her fear of the next couple of pounds or whatever the focused issue might be and all of a sudden I see her eyebrow go up, I stop talking about the weight and stuff and I go what just happened? So you’re paying – you’re working more at the level of what just happened affectively, you know, it gives me a moment. If you unpack that moment, I notice her eyebrow go up. I said something about it so she communicated something to me. I thought it meant something. I can then go back and check that with her. So there are things like that that you can start to use as examples of how you train people to be more in the room. The other way, this for me personally but I’ve heard other people talk about it in their own experience, for me as a man in the field still mostly with female clients, female staff, I call it the therapeutic use of ignorance. Like my willingness to go in and say I don’t get it. I don’t know what this feels like. I’ve not lived this but I’m willing to find out and understand, so teach me. Extremely powerful and I actually try to tell parents that, particularly the dad sometimes like you don’t have to know. You just have to be willing to be moved and changed by it, and if you can communicate that, you’re engaged. So there’s another little piece of how you can teach therapistS or newer therapists to pay attention to have a connect to people in the room.
Kathy: You know I think you’re presenting — I’m coining a term right now, a warm curiosity that we might want to have in the room.
Doug: I think that’s a great combination. That is it’s warm, it’s persistent and this is where it gets wiser, more complicated because it has to be warm that it’s got to be gutsy too like you’ve got to — it’s a wise therapist when [?] we continue this theme, you got to be pretty fearless like you got to go in and ask questions that no one else is going to ask. When people say I had a hard time last night, you don’t go I’m not warmly curious about that, I would be go — you know –
Kathy: Tell me more [laugh].
Doug: I wonder what that was like. What does that really mean? Did you binge? Did you purge? How many times? What was that about? Like and no one else [inaudible] usually is asking folks that kind of question, so you’re actually as a therapist in that situation, decreasing avoidance of the things, you’re doing all sorts of things that we know and the evidence and the literature of the things that move people out of their eating disorder but you’re doing it in a very personal relational way. So you know, while I’m asking that question I’m not going to be sitting back going, “what does it mean that you had a hard time?” I’m like sitting forward in the chair, my hands are going all over the place and, you know. So I’m warmly, actively, genuinely sort of interested and curious and I think for a lot of the relational skill set of a successful therapist is that they learn how to convey fascination. You know, I really want to understand what this is about.
Kathy: Some — and I would like you to if you would please the gutsy nature of being a therapist in this field, it really does demand that because we need our clients to be gutsy too. So one thing we’re doing is modeling but by not letting up in a good way [laugh]. Can you tell us more about that?
Doug: The issue of gutsiness, fearlessness or the willingness to use the words that people aren’t using or to ask the questions that people aren’t asking, I think it’s the greatest gift we give but younger therapists to our clients, younger therapist are anxious, right? So part of wisdom, I think is also you get to a point where you’re confident and you know I can actually ask this and it’s not going to get me in trouble or I’ve asked it so many times I know it usually leads to something useful and I’m not going to really hurt someone with it. Younger therapists tend to be — good younger therapist tend to be fairly cautious about stuff which is absolutely developmentally appropriate. That part of my job and challenge as a mentor, supervisor, teacher, whatever is to help people figure out when they can take a risk to actually put it all out in the table and speak honestly about what’s going on and probably the most obvious example is when people, clients, patients are not really using the real words to describe what they’re doing and you let the euphemism sort of pile up and you never quite get to what they’re really saying.
Kathy: Like it or they –
Doug: Like that or you know, I used my behaviors or things like that. And I will caveat that and say there are times when it’s appropriate to not go there but I think sometimes we often air [?] in the wrong direction on that. There’s a risk on the other side too and I’ve talked a lot about the importance of atunement and connection and this notion of clicking and how clinical wisdom is, you know, really founded on the ability to connect but I really want to stress too that it’s not enough to just connect and I think we see a lot of young therapists come in even though they may have been well trained in technique and behavioral management and CBT and DBT and ACT and so forth, they still doubt that they have techniques and interventions that are effective and they fall back I think sometimes defensively on prioritizing the connection like I feel really connected or we’re really connected. And I’ll be working with them in supervision or in team meeting and we will see that the connection is there but nothing is changing and you’ll sort of look at the transcripts or listen to the tapes and there is not enough challenging going on. There is not enough sort of inquiry and suggestion and teaching by the therapist about what needs to be different and really working out of the CBT canon of just psycho education and things like that. So navigating between being prioritizing the connection versus prioritizing technique is where the wisdom is but you’re not going to be effective if you’re just working on either end of that continuum.
Kathy: You know, a lot of our conversation I think will be, hopefully, very useful for clinicians but we also have individuals who are working on their recovery listening. We have their parents, we have their loved ones, what might you want them to know about clinical wisdom and what they might look for?
Doug: And so if we often — you know, I worked with NEDA, we’ve worked together five different projects trying to educate patients, clients, family members about how do you know whether the therapy is useful, working? How do you evaluate whether this therapist is the right therapist or not. And you can look at CVs and resumes and see what technique they’re trained in but there is something about, you know, we talk about did you click with that person? That no one has really defined but I think it’s worth at least putting onto the check list of whether this is the therapist I want to work with, do I feel comfortable with them, do I believe they’re speaking the truth? Do they get me? And these are more subjective, almost experiential dimensions that are harder to quantify but I would just encourage and empower parents and family members and loved ones, clients, patients to have that on the list like do they feel like this person gets me? Will they speak the truth to me? Certainly one thing this will be a test question for a client [inaudible], if I fight back and say something to you, are you going to retaliate? Are you going to take it? I mean, this may connect to a different topic a little bit but if I had one question to ask is the patient going in beyond the basic, you know, have you treated people with eating disorders and so forth,. Yeah, I’d want to get some sense of how well they know themselves and get the sense that they’re going to bring their own emotional reactions into the work like, you know, what do you call – are we going to use each other’s names? What’s this relationship going to be like? I think it’s a big part of what makes therapy effective and probably makes relationships effective in terms of helping recovery is the capacity for the person with the eating disorder to have a sense that she — I want to [?] say she has actually moved and changed the other person. So to create that opportunity in therapy means the therapist has to be aware enough of what he or she is feeling to be able to then communicate back to the client or patient. I have been moved by you or you’ve changed me or I’ve learned something from you or you’ve mattered to me in some way and there are not a lot of [inaudible] therapies that will have a chapter on how to communicate this sort of stuff but I think it’s an essential part of being a wise therapist.
Kathy: Doug, I can’t thank you enough for your clinical wisdom and your willingness to share it with us today. Our guest today has been Dr. Doug Bunnell and we wish you well. Thank you.
Doug: My pleasure. Thank you.