Social Impact LIVE: Molly Carmel on DBT and Eating Disorders

October 16, 2019 @ 4:30 pm

Molly Carmel, LCSW, is founder and director of The Beacon Program, which uses dialectical behavioral therapy (DBT) to address compulsive overeating, food addiction, and eating disorders. In this engaging interview she explains how DBT is applied to this range of behaviors, and she provides a into her new book, Breaking Up with Sugar, released by Random House in December 2019.


Richard Hara:  Hello, and welcome to Social Impact LIVE, a weekly conversation with members of the Columbia School of Social Work community. I’m Richard Hara, I’m your host, and I’m pleased to have here today Molly Carmel. Molly, welcome. Ms. Carmel is the founder and director of The Beacon Program, specializing in the treatment of weight management, eating disorders, and addictions. She has extensive experience utilizing DBT for substance users and eating disorders, and has completed the advanced intensive training in DBT with Behavioral Tech LLC. Before creating The Beacon, Ms. Carmel also created Greenlight, a successful weight management program at the Wilkins Center in Greenwich, Connecticut, and at Webster Wellness Professionals in St. Louis, Missouri. Ms. Carmel’s work has been featured on the Today show, The Dr. Oz Show, Dateline NBC, Anderson Cooper 360, and Extreme Makeover, as well as in People magazine and the Los Angeles Times. She received her bachelor’s degree in Social Work from Cornell University and her master’s degree from our own Columbia School of Social Work. So welcome, Ms. Carmel, to Social Impact LIVE.

Molly Carmel: Well, great to be here. Thank you.

Richard Hara:  Reading your bio and thinking, right, you were here at the School of Social Work, and then years later you’re on The Dr. Oz Show. How does that happen?

Molly Carmel: I know, I think through a series of luck. One of the things that isn’t in my bio is that probably like my second year out of Columbia, I was working at Phoenix House. I was working in addictions and, you know, this thing that I do is like, it’s really a part of my path and I’ve been passionate about treating food and weight disorders my whole career, and I really couldn’t find the path to it. I went into addictions — to me it felt the closest. I didn’t find eating disorder treatment to be sufficient in what I wanted to be doing, I wanted to do addictions, and within knowing people in that field, I was recruited to start the first ever therapeutic boarding school to address adolescent obesity. When I was about 25 years old, I was recruited to the Central Valley of California. And largely because I followed my passion, and I think largely because I came with a really solid education, and maybe because I was willing to move to the Central Valley of California, and I started that program there and that’s really where this part of my career took off. It’s where I started my training in behavioral weight management, was able to synthesize some of the other parts of the work that I think are essential in treating food and weight disorders.

Richard Hara:  Okay, wonderful, so you’re well traveled.

Molly Carmel: Well, yeah, if you call Fresno well traveled, I absolutely am.

Richard Hara:  All right. You’ve worked as a clinician. You’ve developed programs, right?

Molly Carmel: Yeah, I’ve been a program developer since I was 25, yeah.

Richard Hara:  Yeah. Also a book author, I understand that you have a book coming out at the end of this year.

Molly Carmel: I do. I have a book out December 31st — so New Year’s Eve drop the ball, read the book — with Penguin Random House called Breaking Up With Sugar. It’s, I mean, talk about beyond my wildest dreams. And without my career I wouldn’t be able to write it. So it’s really exciting.

Richard Hara:  We’ll definitely be hearing more about it, I’m sure. Also, I understand there may be some promotions associated with pre-ordering, so wink, wink, nod, nod.

Molly Carmel: Yeah. Wink, wink, nod, nod.

Richard Hara:  We’ll get that information to you a little bit later on. But, yeah, I’m just – I’m just fascinated about how you’ve sort of specialized, right, in DBT as part of your clinical training and how you’ve taken principles from that modality and used them in your work with weight management, and so on.

Ms. Carmel:  Yeah, I mean, I’m — and I need to say I’m obsessed with DBT. I think that, and I’m really well trained in it. I was lucky enough when I was, I guess about 12 or 13 years ago, I was gifted by, when I was working at the Wilkins Center, I was gifted to spend about five days with this fantastic DBT clinician Alan Fruzzetti. He was very well known as a couples therapist then. When he started — and I took it a little bit at Columbia, but it was a different time, it was before there was a lab here, and I’m a little older than I look maybe. But what I started to understand about DBT and the research suggests this as well, is that DBT is well utilized for a lot of things that maybe people don’t know about including eating disorders and addictions. But, to me, the idea that it’s a — it’s a principle-based treatment with protocols, right? Which means like, in my experience being a clinician, I never know what I’m walking into, right? If I have to follow like this exact regime all of the time, I’m probably not going to be as effective as a clinician.

The other thing that I deeply love about DBT, maybe the most of all is how incredibly humanizing it is. How DBT has agreements, like this is a relationship between two equals, and this idea of really being like a change-oriented… I almost sometimes think of myself like as a consultant someone hires to getting the job done with them, but that incl — with these validation techniques. Of course, I don’t know if you all know this, but DBT is made for the treatment of borderline personality disorder, and incredibly effectively research, you can go read that all day, there’s nothing — nobody does research like Marsha Linehan, right?

Richard Hara:  Okay.

Molly Carmel: But to me, with food and weight disorders and eating disorders, the diet culture, right, this diet culture is making promises to people who have — and effectively like a diet is maybe somebody who needs an aspirin, right? But if you have an eating disorder or a food addiction, you need like a Cipro, right? A lot of people are here eating aspirin over and over, wondering why they’re not getting better and having people make like sincere promises. In DBT, we would call that chronic invalidation. There’s a piece of the work in DBT that I think is a no-brainer in treating eating disorders and food addictions because it’s made to treat chronic invalidation. People who come in my office are certainly not diagnosed BPD by any way, but they come with a lot of those symptoms as a function of the diet culture.

Richard Hara:  Yeah. That’s maybe something that maybe I don’t understand about DBT, I know that it’s obviously got a behavioral component to it. I know that it was developed to help treat borderline personality disorder. But it has components, right, and there’s mindfulness and there’s emotional regulation, et cetera. But what is it that’s dialectical? I’m – yeah, what is that piece?

Molly Carmel: It’s to say like, so when Marsha was creating the treatment, she was just there to cure suicide, right? Like she’s just like, I’m going to cure suicide. When she tried change strategies, and she would say, okay, like, here’s how we’re going to fix you, her beta testers were like, excuse me, do you understand how hard this is for me? Marsha was like, back to the drawing board. Then she would go in and she would do like a more validation kindness, wow, this must be so hard, like really validating. People would say, oh my God, don’t you understand how badly I want to change? Right, and so Marsha, I think, came to this conclusion and said, well, we need to find synthesis between helping people change and using validation to get them there, right? There are a lot of principles within this validation part of DBT that I think is what gets the — really gets people over the line of change is having an incredibly validating therapist and all these other techniques. I mean, there’s a whole manual just in the validation techniques of this.

Richard Hara:  Okay, so your premise is that I mean, weight loss, and everything that we talked about with regard to obesity being an epidemic in American society today, is sort of similar to this kind of dynamic that people are trying to do things but they’re not being validated or —

Molly Carmel: Well, I think I mean, first of all, if you want to talk about a great two opposing ideas in addiction, in food and weight disorders, which would be I really, really want to change and I really, really don’t want to change, right. I really, really want to not be caught up in an eating disorder or food addiction, but I really don’t want to stop eating or throwing up or doing whatever you’re doing. I mean, that’s a real pickle, wouldn’t you say?

Richard Hara:  Okay, sure.

Molly Carmel: What DBT suggests is that we help find synthesis within these two ideas that there’s truth to both of those sides and that’s what a true dialectic is, is that we honor that there are truth — Part of validation truly is honoring that there is truth to both of those ideas, and that it is really hard to make a change.

Richard Hara:  DBT can help by doing what?

Molly Carmel: Well, DBT certainly validation is not going to get somebody well, it’s just going to push them over the edge. Something I love about Marsha is that she always makes this assumption. Marsha Linehan, the founder of DBT, the treatment creator. But this idea that people really have a skill deficit, right, and gosh if you failed at a million diets, you’re going to really take that personally, you’re going to really think that you’re the problem, right? I would say, by the way, like the diets are the problem, you probably didn’t take the Cipro when you need — you’re taking Advil the whole time. But, also I think there’s a tremendous skill acquisition that needs to happen both in understanding what to eat… There’s a lot that happens when we have to recover in being able to regulate and finding out what foods work and what foods don’t. But here’s the real kicker in my opinion. I think of this with all substance, with all addiction. The thing that you’re doing can no longer be the coping skill, right? So with food and weight disorders, and certainly with binge eating, we have to take that off the table as a coping skill, right, which is like being a hole in the donut at the end of that, right? It’s like, if I want to change my relationship with food and all I’m doing is using food to cope —

Richard Hara:  To cope, right.

Molly Carmel: — I have to find a whole new way to live. Because Marsha Linehan actually says — one of my favorite things that she says — she says, “As long as the problem behavior is still being utilized, change is impossible.” That’s a big piece, is learning how to tolerate life without using food, that’s probably the biggest part of it, right?

Richard Hara:  Is it possible to just take away that coping mechanism and then put in another one, or do you need to put another one in first so that then you can —

Molly Carmel: It’s such a good question. What I usually say — I mean, yes and no, or DBT as we would say, it depends, right, it depends who you are, and it’s a bit of a snowflake question. But I think the thing about the — and by the way there’s two chapters in my book devoted entirely to this. The first one, if you want to — a lot of people who’ve been around the way in dieting or making any change, like it’s not unfamiliar that you would say, hey, why don’t you journal instead of taking drugs, right, but people find that really invalidating like, you clearly don’t understand how bad my pain is. But when we’re at this turning point that says, “Well, you can’t change unless we figure out something to do differently,” we have to sell that to people. I think, by the way, being a therapist is really being like a negotiator and a salesperson, right, and a validator. I think that those are really the three skills that we need. What I talk about in my book is like, we have to date these skills, like literally take them on dates, because if I’m in my kitchen and I’m like ready to go on a binge, like, there’s no way I’m using a skill that I don’t know works, right? So we have to, in DBT language, we would say something more like, we have to be able to — we have to practice skills when we’re not activated, because then we’ll practice them when we’re activated. If I don’t know that I love listening to music when I’m calm, I’m certainly not trying it when I’m about to reach for a cookie, you know what I mean?

Richard Hara:  Okay, all right. I just want to jump in here and remind our viewers that we will have a Q&A during the last 10 minutes of the program. So think about your questions, and you can write them in the chat box.

Molly Carmel: Get ‘em ready.

Richard Hara:  Then we’ll have them here. Okay, so the title of your book is Breaking Up with Sugar. It seems to me that you’re talking about a relationship, okay, and that a lot of what we do is predicated on interpersonal relationships, right, and so and so. How does that work with as far as —

Molly Carmel: By the way, there’s only two relationships we need to have in this lifetime, right?  And one is with food and one is with ourselves. Otherwise — and maybe like, air, but still, right? But I think that there’s this really fascinating piece of this, which is like, well, we’re making this into like a destination and a diet. Like a diet’s not solving a relationship problem, right. One of the big pieces of DBT that I use in this book is — is in the DBT for substance use, and that’s called dialectical abstinence, and it’s an interesting way that people who are have chronic diet problems behave with food. I mean, it’s — this is not a clinical term, but it’s like very crazy, right, because somebody wakes up and they say, oh, it’s Monday I’m going to go on my diet, it’s going to be amazing, and they go to work, and there’s donuts on the table and they take a bite of the donut and their reaction, you know what their reaction is, right?

Richard Hara:  What?

Molly Carmel: Like, they just throw caution to the wind. Like, oh I had a bite of donut, like, game on, like. And then it’s like pasta for lunch and frozen yogurt for dinner, and it goes on and on and on. It would be like if you got a flat tire in your car, and you got out of the car, and you sliced all four tires, and you left the car in the middle of the highway, right? By the way, if you want to know trauma, I mean, right? I mean, if you want to know chronic invalidation, it’s like, that is self-harm in my opinion, right. If you’re chronically doing that to yourself, people have really lost trust in themselves. But more importantly than that, from a relationship perspective, it’s like there’s no relationship in anybody’s life that would work if the first thing they did when something went wrong is to quit the relationship. Like, you ever have a hard day at work?

Richard Hara:  Sure.

Molly Carmel: Are you like I’m out of here, Columbia.  Nice to know you! Like, right?

Richard Hara:  Right, right, yeah.

Molly Carmel: We have ideas about that for sure, for sure. But, there’s not none of us that are like —

Richard Hara:  You got to make the relationship work, or at least try to make it work, right?

Molly Carmel: Or make a corrective action plan.

Richard Hara:  Yeah, yeah.

Molly Carmel: You know, try not to do it again, get right back on. Have a little meeting with your staff.

Richard Hara:  Sugar is not the enemy per se, right?

Molly Carmel: No, sugar is the enemy.

Richard Hara:  It is. Yeah okay.

Molly Carmel: For some of us actually. I’m not here to diagnose, but, so there’s a quiz in the book.  You decide.

Richard Hara:  All right.

Molly Carmel: But from a chemical perspective, there are people who have conditions with sugar that are — will match cocaine. You will take that DSM5 quiz and you will win. I mean, I’m in recovery from a sugar addiction, I’m a 12 out of 12 on that thing. There’s a Yale Food Addiction Scale, I mean this book is…. I love DBT, I love science. I’m well trained. This book is rooted in science. There is this long of the endnotes of this book.

Richard Hara:  Yeah, I was going to ask about the empirical evidence and sort of testing, you know, you are —

Molly Carmel: I’m of the old generation. I think truly, like, being really rooted in DBT has almost trained me to say, well, what does the research say? Well, what does the re-? None of — there’s very, very few independent ideas in this book. I really like to rely on what people have done before. Frankly, my clinic in New York City, we’ve been practicing this for six years, and so and had pretty remarkable success with people who otherwise were not getting well. I mean, you have to remember the idea in eating disorders –, and let me tell you one other thing about eating disorders and food and weight disorders: there is no evidence base. I mean, that’s the — so we’re all just doing our best, right, but there’s a huge belief in this eating disorder field that moderation is the only way, and I always say, like, “One way? Run away,” right. We don’t actually know what works. I’m just introducing a new model, right, which would be a — I would say like a harm-reduction abstinence model, like we try not to — it’s what dialectical abstinence says is like, we try not to do it ever, but if we do it, we get right back on track, right, like we do in all relationships, right?

Richard Hara:  Yeah. Again, going back to DBT sort of being created in response to the failure of traditional therapies, right, with patients with borderline personality disorder. At some level, are you looking at food addiction and these weight ma– as something rooted in people’s personality or —

Molly Carmel: I don’t think so at all. But no, no, no, but I do think that I’m offering a different paradigm because in my own experience and the first 10 pages of that book is my own experience. Like, I couldn’t find a place that worked, and so like Sebastian in The Little Mermaid, I was like, you want something done right, you got to do it yourself. A lot of this has been informed by my own experience, but my own experience informed by empirical evidence, what I know works, taking from DBT, taking from an addictions model, taking from a harm-reduction model. But I don’t think it’s a — I mean, I think it’s a — I think like all addiction, I think it’s biological, I think it’s psychological, I think it’s the nature of the person, I think it’s the nature of the environment, I think it’s the nature of the substance. I think it’s the perfect storm. The only thing I can say about food that is different than traditional addiction is that it impacts the nervous system like dopamine, but it also is — and this is where the real epidemic comes in —  it’s a function of the endocrine system too. So eople who may not even be so neurologically addicted have endocrine with insulin and cortisol, and it really looks — this addiction is — it’s tough in that way.

Richard Hara:  The treatment, I mean, the clients that you see, we have some idea of what the content of the work might be like, but — I mean, how long does it take? What do you — and I’m sure it varies by individual, but what are people looking at, because it seems like a big task here?

Molly Carmel: The thing is  — it’s such an interesting question, because it’s a — it’s how long does it take to heal a relationship? I don’t know, I think that that’s sort of what we get into a diet culture, right? I mean It’s like — I mean I think it takes — by the way, it’s not what I think, the research says, right, it takes 66 days to get some level of automacy, right, for our brains to sort of say, oh okay, I can do this day in and day out. But the truth is with any addiction, it’s like the answer is not when does it end? The answer is like, well, what does my recovery look like? How do —

Richard Hara:  Step by step.

Molly Carmel: And how do I maintain this relationship? It’s like, if I stop taking my blood pressure medicine and my blood pressure went up, it would be no surprise what I would have to start doing again. I think that’s really what I’m trying to say, is that this takes a minute, right, and this is like, getting into relationship with food and getting into relationship with yourself is the only answer. It’s a very unsexy answer by the way.

Richard Hara:  Well, and developing the skills, right, to manage those relationships.

Molly Carmel: Thousand percent, thousand percent.

Richard Hara:  Okay. Well let’s, let’s go to the questions. Do the four steps of DBT as they are applied to bipolar disorder translate well to food and eating disorders or are there modifications to the protocol?

Molly Carmel: So, I’m going to try to— Hi. I’m going to try to answer this question the way I think it’s being written, and so apologies if not. But I think what we’re talking about are the four modules of DBT: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Absolutely, they absolutely translate to, and what I want to say is that there actually is a DBT for eating disorders and DBT for bulimia. There is a book, it’s great. My spin on it is that I don’t believe in moderation, and I also believe wholeheartedly that in order to be in recovery from an eating disorder, you need to have a really good knowledge and relationship with food. And so at my clinic The Beacon, we deal with food there. And so the way that we do it in DBT, which is where we have a target behavior, we have a diet card and all of that, we have people write down their food and we use the food as the target behavior in individual therapy and then adjunctively have skills groups where we take some of the greatest hits of the DBT. But, without question, I mean, I got to be honest, I think that DBT translates well to life, so there’s that one too.

Richard Hara:  Okay, and for people living their best life.

Molly Carmel: Oh, a life worth living as Marsha would say.

Richard Hara:  All right, next question. Have you ever tried parts work, Richard Schwartz, with DBT? It seems consistent with the idea of dialectic:  being able to acknowledge the parts of you that want one thing and the parts that want another, then facilitating dialogue between those parts?

Molly Carmel: Great question. I’m really into this. I could be here all day. But, so that question, the parts theory’s not consistent with DBT although it certainly smells a little like addict-, traditional addictions therapy, like calling something like the addict. In DBT, for substance use, there’s a wonderful skill where Marsha calls it like the addict mind, the clean mind, and in the middle of the dialectic of that is the clear mind, and that would be a little bit consistent I think with a parts idea of like, oh, that’s my addict mind working right now or, oh, that’s a clean mind thought. I certainly use DBT as my primary use in the work and I — but I pick those little parts work every now and then. I think there’s certainly a similarity, you can find that, and in the core of Marsha’s work, wise mind, reasonable mind, emotion mind, you can be saying, oh, wow, that’s a real reasonable mind thought right there, and so maybe that’s not working for me.

Richard Hara:  Okay, so I see — now I’m starting to see the dialectic, right?

Molly Carmel: You know what I mean?

Richard Hara:  Hegelian kind of thesis, antithesis, and synthesis, is that what — [Crosstalk]

Molly Carmel: Look at you, there you go. I guess like you’re like — we could — you’re done! [Crosstalk]

Richard Hara:  Okay. Yeah, sort of coming to that point where you’re able to — I don’t know if it’s resolve or at least hold two different truths.

Molly Carmel: Yeah, and I think identify like, oh look at that I’m swinging too left today like, oh, look at that. I’m like, I’m really, really — and by the way clean minded in addictions is like, Oh no, I’m fine. Like, I can sit at the bar! Like, Oh, I’m good. I’ll carry the cupcakes to the party. Who, I got this! Right? That’s arguably, I think, especially in binge eating and in compulsive overeating, like, that’s actually the most dangerous of all, right? It’s like, Oh, I didn’t need to have my snack, I’m fine, because restriction always leads to binging. It’s an interesting thing to be able to identify like, Oh my goodness, my thinking is not consistent with who I want to be today. I got to move back over to the middle path there.

Richard Hara:  Okay, next question. A few members of my family have had weight loss surgery without any form of counseling beforehand. How can we get this integrated for people deciding on this form of weight loss to truly change their behavior so the weight does not come back?

Molly Carmel: I mean, that’s a policy question, isn’t it? I totally — I’m wholeheartedly in agreement with that. I don’t know how we can do that, but I wish we could. I wish that people would understand that eating disorders and food addictions are psychological, sometimes spiritual disorders, and bariatric surgery is a medical procedure. Right? And so we want to treat all of these conditions as wholeheartedly as we can, as holistically as we can, to get to garner the best results.

Richard Hara:  Okay. Eating disorder, treatment for eating disorders, they are evidence based and they are covered by insurance?

Molly Carmel: Some of them.

Richard Hara:  Some of them, right? Some of them.

Molly Carmel: You never know, right? Just like all treatment, you never know.

Richard Hara:  Some insurances —

Molly Carmel: Some insurance and some evidence based and some not, right? Evidence based is hard to find around.

Richard Hara:  Okay. Maybe that’s a factor in this sort of gap or disconnect in terms of really comprehensive services being out there and —

Molly Carmel: It’s really why when I created my model, I created… My therapists all diagnose food. So my therapists all do food plans with people under the supervision of a nutritionist because I felt like that’s so many places to go, and it felt so untenable to be able to have that much time to go to — and like and have the team together just in today’s world. That’s at Beacon we do it a little bit differently. I trained all of my therapists in nutrition for that reason, exactly.

Richard Hara:  Given that anorexia has little to do with food, what does DBT do to address the underlying causes?

Molly Carmel: Great question. I’m in love with this. So interestingly enough, there’s a new — not a new, but there’s a radically open DBT, RODBT, that has — they’re trying to create, they’re actually… The thing that actually has zero evidence base is anorexia. So if you want a real, like, roll-the-dice disease, that’s the one. So I think that DBT doesn’t talk too much about underlying disease. It’s a behavioral therapy, right. Arguably incredibly, we — it’s — what’s the word I’m looking for? Well, I can’t remember it, so I’m not going to waste our time thinking of my word. But we don’t really look at underlying issues unless when we’re sitting in a chain, we have to take a moment and look at them, right? And so if you want a more psychodynamic look at anorexia, this would not be the treatment for you, right? Sometimes there’s people even come to my clinic where I’m like, this might not be the thing for you because of the evidence base is so — There is no one thing that works.

Richard Hara:  Okay. We’re distinguishing that from clients who come in with comorbid, you know, um, issues, right?

Molly Carmel: Yeah. It’s like a snowflake, everybody is so different.

Richard Hara:  Okay. In your writing and publishing process, how did you adapt your clinical information into a book that’s accessible to the public? Yeah, I –

Molly Carmel: I know. This was like the most fun and interesting part of writing it, because I think that what I come with is a bit of an ability to sorta, like, People-magazine up some of the research. Actually a woman, Alex Wilt, she graduated two years ago, she — do you know her?

Richard Hara:  The name is familiar.

Molly Carmel: She is one of my favorite humans. She works at Beacon. We are hiring, so if anyone’s want to come work for us, please get in touch with me ASAP. But she is a really great researcher, and so she was my writing partner in this. She would be doing all of this writing, and so she would write it out like very clinically. Then I would like have to sort of read it and say, like, okay, how do I make this like unicorns and sprinkles and glitter so that people will like, want to read it? It’s actually, if you ever saw how that process went on between me and Alex, it was largely hilarious because she would write something, I’d say, oh can’t you just write that like a human, you know like —

Richard Hara:  The way human beings talk.

Molly Carmel: Right, and we just have this great banter together. She’s wonderful, she’s a great gift of mine from Columbia, so thank you, Columbia.

Richard Hara:  So, just the process of trying to just distill it into everyday language about relationships that people can identify with?

Molly Carmel: To be honest, here’s what — and here’s what we did. I would write it in science, I would read it and I’d say sort of like, how do I say this to — how would I say this to a high school student? How would I say this to my friend who didn’t get it? My mother always says to me like, stop sounding like such a therapist, Molly. And I kind of had my mom in my brain, and I’d have a few ideal avatars, is what we called them in writing. I have a few people I would be writing to, and I would think like, okay would this make sense to them? And largely, it didn’t. Also, if you’re writing a book, get beta testers, get honest people who are going to – who care about what you’re writing about. I had seven of them, who’d be like, that’s terrible, or that doesn’t make sense to me, or that feels invalidating. I’d be like, great, let’s change it, you know.

Richard Hara:  Well, I’m always interested in hearing how therapists talk to their clients. So maybe this will be a great opportunity for me to — instead of, right? And yeah –

Molly Carmel: DBT, yeah. DBT talks about radical genuineness. It’s one of the main validation strategies in DBT. So that’s where I come from. I was like, count me in.

Richard Hara:  I’m sorry, we’re going over five minutes. Please stick around, yeah.

Molly Carmel: We are extending our time together.

Richard Hara:  We are extending the time.

Molly Carmel: I’m so excited.

Richard Hara:  Just so we can get everybody’s question. And so my apologies for not keeping track. How does DBT address issues of body image and self-esteem, which so often accompany or are subsequent to primary eating disorders?

Molly Carmel: Yeah, well, so here’s what I want to say about that. I’m not sure that it addresses it so directly, but here’s what I know for sure. It’s really, really, really — I think my second book might be about this, spoiler alert. But it’s really, really hard to like, accept, or love your body when you are harming your body, right? And so to me, in many ways, and like listen, I get body dysmorphia, I get all of it. But from a primary perspective and from, what we would say at DBT, a radical acceptance perspective, is kind of contingent on having really healthy behaviors and doing really esteemable things like the way we get self-esteem, frankly, it’s a behavior. We do esteemable things to ourselves. I think that there’s a base for self-esteem in body image work that says, hey, can I start to do the behaviors I know that are loving towards myself? Can I be able to change behaviors that I know aren’t and substitute in healthier skills in the way? But it’s not a treatment in that way very exactly like —

Richard Hara:  So is that harming behavior? Let me see if I got this correctly. It’s not self-harm, it’s not sort of a kind of soothing — or anything like that. You’re saying that, that it’s –

Molly Carmel: Well, to me if I’m self-harming by binge eating and throwing up, and saying horrible things about my body and body checking and all the things that come with eating disorders, right? Stopping doing that, the behavior of stopping that is going to make my self-esteem much better and give me a shot at loving my body. It’s hard to love your body when you’re harming your body, right?

Richard Hara:  Okay. Okay. Okay. Get that, get that.

Molly Carmel: So behavioral treatment can work plenty on body image, promise you, and self-esteem, promise you that.

Richard Hara:  And a little bit of cognitive therapy as well? I just threw it in, sorry.

Molly Carmel: Yeah, but you know — yeah sure. Some two-chair journaling. I’m with you, I’m with you. [Crosstalk] I love CBT, don’t get me wrong.

Richard Hara:  I — no, I —

Molly Carmel: I’m just here to talk about DBT.

Richard Hara:  So what’s the difference between CBT and DBT in treating patients with dis-, eating disorders the — wow!

Molly Carmel: Oh my God.

Richard Hara:  Who knew?

Molly Carmel: DBT, I believe this is true, is like a — it’s under the umbrella of CBT so we can all be calm about that. I think the piece of DBT that’s very different is this focus on the validation strategies, the skill, the four modules of skills changing like all of that, I mean that’s the difference of it. I’m going to promise you if you’re a good DBT therapist, you’re bringing in CBT in the moment. It’s not always — that’s the thing about DBT.  It’s, it’s jazz, right? It’s movement, speed, and flow, like you really — you got to be really in the moment. There’s nothing like that particular like, no CBT in this, no way. You know, it’s a little bit more fluid than that, it’s like being in a song.

Richard Hara:  You can try to work with some automatic thoughts and do a little bit of reality testing and things like that?

Molly Carmel: Yeah, you will not get arrested by the DBT police, I can promise you that, I can promise you that. Maybe, maybe I’ll get arrested by the DBT police for saying that. What do I know?

Richard Hara:  I’ll take your word. Three more questions. You mentioned relationship, food and self. But what happens to interpersonal relationships, where at times it’s not controllable, right? I mean —

Molly Carmel: Well, first of all I’d like to ask what interpersonal relationship is controllable, because count me in. I think that there is a piece of interpersonal relationships where it’s actually, by the way, usually the thing that we are dealing with. I actually say this like I have done probably 10,000 chains on people binging, and I will say 999,000 of them are interpersonally based — are saying yes when you mean no, saying no one you mean yes, going somewhere, being with people that are triggering you. So learning interpersonal effectiveness — and by the way, we could file that under learning self-esteem — is a huge part of living a healthy and life of recovery from an eating disorder. I hope that answered the question.

Richard Hara:  Yeah. Well, I mean, there’s the uncontrollable outside, right?

Molly Carmel: Well, life is — I mean, I write this in my book, man. Life gets lifey. We got to learn how to — Marsha would say like we got to play the hand we’re dealt, right. There’s nobody who’s going to get a perfect life, so better learn how to manage that.

Richard Hara:  Control within is also — it’s not an all or nothing thing, right, so.

Molly Carmel: No, oh my gosh, I’d be totally screwed if it was, wouldn’t you? Am I allowed to say that word?

Richard Hara:  What is the difference between this and sending a patient to Overeaters Anonymous, where they deal with all types of eating disorders and addictions and offer daily support?

Molly Carmel: Fun factoid, which is that there is a research study that puts the Twelve Steps and DBT sort of parallel, right? And so there are a lot of similarities. I will say that the number one thing is that DBT is like professionally run, and in Twelve Step organizations there’s no talking through. You share for your three minutes and then you’re sort of done and you have your friends. But there’s a professional piece of this. There’s an evidence-based piece of this. Overeaters Anonymous doesn’t do the skills as exactly as this, but nobody loves — what I would say at Christmas time to my clients — it’s like no one ever complains that like they’re not supported enough. Like, more support, the better like a — the opposite of addiction is like connection. So I love a good support group. You’ll see me there.

Richard Hara:  There may be similarities and — but overall —

Molly Carmel: I mean, one is professionally run, right. The other one is like a peer support group. So they are all good though, don’t get me wrong.

Richard Hara:  Yeah, yeah and can have some value for people depending on their needs.

Molly Carmel: Absolutely. But I also want to say to maybe answer questions like, I actually think that if you’re in DBT, go to Twelve Step because they’re going to really be in such a great language with you.

Richard Hara:  Okay, great, great. And DBT also incorporate some group work as well?

Molly Carmel: Oh, sure. There is a whole group component about that, for sure.

Richard Hara:  Right, final question. How does the idea of radical acceptance work with respect to treating eating disorders?

Molly Carmel: I love this question. I mean, how does the idea of radical acceptance work with life? But in order for us to have any level of change, we have to accept what’s going on. And the truth is that people are like, well, if I really accept this thing, then I’m really going to go all out with my eating. But that denies the idea that we have wisdom inside of us, and that when we really tap into this wisdom, what I always say is like, when we’re in our wisest mind there is no overeating, right? Tthere is — it doesn’t make sense. And so radical acceptance is, after interpersonal effectiveness, it’s the second thing I’m talking the most about. It’s like accepting what is true and what you know about the true nature of your condition is the way that we start the healing. It’s the exact, it’s the jumping off point of the healing is accepting what is true, right?

Richard Hara:  Okay. All right, well, I hope that our viewers today have an opportunity to read your book.

Molly Carmel: Could we tell them about the website really quickly?

Richard Hara:  Can you just — yeah please do.

Molly Carmel: Here is this exciting thing. I have this website, it’s called and you can buy the book on that website. Then you get to get the first chapter of my book, and get into this amazing Facebook group that we’re on every single week, and maybe get a session with me. Isn’t that — ? Get on it! If you sign up there, you get on everything and it’s so exciting, and I don’t know. If it’s exciting to you, it’s exciting to me.

Richard Hara:  Well, we’ll post information on our website —

Molly Carmel: That’s wonderful.  Thank you.

Richard Hara:  — and so people have that available. That concludes today’s episode. We’ll be joined next week by Columbia School of Social Work faculty member and University Professor Nabila El-Bassel to discuss her work intervening in New York’s opioid crisis. So, once again, thank you, Ms. Carmel, for joining us today.

Molly Carmel: Thank you.

Richard Hara:  Thank you all for viewing and see you next week, bye.

Molly Carmel: Bye.