Participating on an FBT Team

Image by griffert from Pixabay

Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.

Overview of FBT (3 phases)

Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:

  • Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
  • Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
  • Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
  • Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
  • Externalization of illness—the illness is seen as an external force that is threatening the child’s life.

FBT consists of three phases:

  • Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
  • Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
  • Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.

When to Add Other Providers

Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue and then on eliminating symptoms. Medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.

Family-Based Treatment Teams

Dietitians

For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.

The situations in which I have found the dietitian to be necessary include the following:

  • The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
  • The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
  • There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
  • There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
  • The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.

Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.

Individual Therapists

Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.

Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:

  • Dialectical Behavior Therapy (DBT) therapist addressing emotion regulation
  • Exposure and Response Therapy (ERP) therapist addressing obsessive-compulsive disorder (OCD) or symptoms
  • Adolescent therapist addressing comorbid anxiety, depression, self-esteem, or interpersonal issues

The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”

On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful  DBT teams that focused on teaching the adolescent skills to manage her distress while not attempting to question or undermine the parents’ authority over food decisions.

Advice for The Individual Therapist

My advice for the individual therapist:

  • Don’t blame parents for causing ED
  • Don’t disempower the parents
    • Don’t question parents being in charge of food
    • Don’t suggest compromising on food choices
  • Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
  • Don’t focus on empowering the adolescent to share frustrations about parents being in charge
  • Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
  • Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
  • Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
  • Help the adolescent fill their life with other things
  • Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
  • Let the adolescent vent about their frustration over parents being in charge
  • Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them

 

Nana’s Poundcake, Food, and Cultural Connection

Nana's PoundcakeFood for us comes from our relatives, whether they have wings or fins or roots. That is how we consider food. Food has a culture. It has a history. It has a story. It has relationships. –– Winona Laduke

Food is about more than sustenance. It is about pleasure and joy and connection. Food is one of the ways we connect with our cultural traditions and our ancestors. This is one of the reasons I am so passionate about my work to help people with eating disorders. When someone has an eating disorder and they are fearful of eating or of eating certain foods, they miss out on the pleasures of food and they miss out on the opportunities to connect with others through food. They also miss out on their own connection with their relatives and their cultural heritage.

In my own family, my 103-year-old Nana has always been known for her piano playing and her delicious poundcake. While her prized Steinway piano now stands in my home, I did not inherit her piano-playing her abilities. I did, however, learn her poundcake recipe.

From the time I was a young girl, I have memories of “Nana’s poundcake.” Simple to make with only 5 ingredients, buttery and yummy. During visits to Kansas City, I looked forward to making it with her. And when she visited us in New York we would make it together. And, occasionally my mom and I would make it without Nana. My kids have had the experience of making poundcake with my Nana, their great grandmother. And they have made it with me. After she eventually passes, we will retain this connection to my Nana and my kids will hopefully continue to make and share her recipe with future generations.

 

 

 

 

 

Photos of my daughters making poundcake with Nana back in 2012 at her apartment (she was 96)

I am glad to have this connection to Nana and to be able to fully enjoy making and eating poundcake with all its rich butter and sugar. What joy and connection I would be missing out on if I were afraid of eating it. To be able to make it and eat it with enjoyment enriches my life and allows me to have a shared experience through four generations of my family. I will always have joyful memories of baking and eating poundcake with the different generations in my family.

Bonus Feature — Nana’s Poundcake Recipe

  • 1/2 pound salted butter (2 sticks) – softened
  • 1 3/4 cup sugar
  • 5 eggs
  • 2 cups sifted flour
  • 2 T vanilla

 

  • Cream butter and sugar
  • Add eggs one at a time while beating constantly
  • Add flour and flavoring
  • Pour into well-greased loaf pan (or bundt pan)
  • Bake at 350° for 90 minutes

Photos from a poundcake I made with my daughter in 2019.

When Your Child With an Eating Disorder is Sick….

Guest post by Dr. Jennifer Johnson

When Your Child with An Eating Disorder is Sick...
Gambar oleh Clker-Free-Vector-Images pada Pixabay

When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.

First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.

Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)

What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?

If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.

What about if they have a fever?

Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.

What about when kids in recovery have the stomach flu?

What do you do if they’re vomiting?

Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.

What about diarrhea?

For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.

One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.

What if your child has no appetite (due to illness)

Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!

Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.

About Jennifer Johnson, M.D., MS, FAAP

Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.

Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.

Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.

Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News. 

Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.

Parent Volunteers Needed for Eating Disorder Recovery Research Study

Parent Survey Eating Disorder

 

Mayo Clinic researchers are conducting a study examining parents’ perspectives on eating disorder recovery. We believe that parents have valuable information about their children that can help us better understand eating disorder recovery and improve treatment outcomes. If you are a parent of a child or a teen with an active or past eating disorder, we would appreciate your input by taking an online survey. If you are interested in participating, please click on this link:

Parent Survey of Recovery

You may share this message and link with anyone else or any group that you think might be interested in participating.

This survey is for parents who:

  • Have a child or a teen who was diagnosed with an eating disorder before the age of 18
  • Have access to some data about their child’s heights and weights prior to diagnosis, at diagnosis, and after diagnosis (any measurement system is fine!)

We will be asking you questions about your child’s illness and aspects of recovery, including weights and heights if you have them. If you have growth records, it would be helpful to gather them before taking the online survey. The survey should take about 30 minutes to complete and will be anonymous.

Study Information

Understanding Carers’ Experience in Treatment for Their Child’s Eating Disorder

Principal Investigator: Jocelyn Lebow, Ph.D.

Additional Investigators: Erin Accurso, Ph.D., Leslie Sim, Ph.D., and Lauren Muhlheim, Psy.D.

You are being asked to participate in a research study to understand carers’ experience in treatment for your child’s eating disorder. This invitation is being posted on blogs, social media groups and sent to listservs for parents of children or adolescents who have had/ currently suffer from an eating disorder.  If you agree to participate, you will be asked to spend approximately 30 minutes completing an online survey. We will ask you questions about your experiences during your child’s treatment and your personal definition of “recovery” for your child. The survey is anonymous, so your answers cannot be identified or traced back to you.  The risks and burden associated with this research study are minimal. While there is no direct benefit to you if you choose to take this survey, we believe that this research study will provide a better understanding of carers’ perspectives of their children’s treatment and recovery, with the goal of improving treatment and outcome assessment.  Please understand that this is a voluntary study and your current and future medical care at Mayo Clinic will not be affected by whether or not you participate. Contact the Mayo Clinic Institutional Review Board (IRB) to speak to someone independent of the research team at 507-266-4000 or toll-free at 866-273-4681 if you have questions about rights of a research participant. Thank you for sharing your time and expertise.

 

The researchers

Sweatin’ for the Wedding: Say, “I don’t.”

Sweating for the Wedding? Say: I Don’t.
Image by rawpixel on Pixabay

by Carolyn Hersh, LMFT

In November of 2018, my boyfriend proposed to me. It was one of the most exciting days of my life thus far. With a proposal comes the next exciting chapter: wedding planning. For many brides-to-be, this entails finding that perfect gown.

Sadly, although not surprising, once I got on bridal mailing lists, I learned I was also being targeted by gyms for “Bridal Boot Camps” and “Sweatin’ for the Wedding.” The weight loss industry found yet another way to weasel their way into a life event that should have nothing to do with changing one’s body.

Why is it that you could be with someone who you love for a certain amount of years, and suddenly the moment they place a ring on your finger you need to change your body? Why does looking beautiful equate to weighing less?

Unfortunately, it has become the norm in our culture to experience pressure to lose weight for special events. A friend once shared that when she was dress shopping her consultant actually wrote down smaller measurements because “all brides lose weight.” When my dress consultant mentioned letting her know if I lose weight, my initial thoughts were, “Are you telling me I need to lose weight? Am I supposed to lose weight? What if I like my body where it is? What if I want to gain weight?”

Granted, our bodies can change. But, hearing about weight loss, exercise programs, and diets specific for the big day can be detrimental to our physical and mental health. The diet industry has found another market and doesn’t care how it impacts the people getting married.. Wedding planning can be stressful enough with trying to create a special day without the added pressure to create a “perfect” body.

But, here is the thing. Your fiance asked to marry you not because of what you’ll look like on that one specific day, but because they are in love with you and everything about you. Getting married is about making a commitment of love to one another. Your wedding day should be a celebration of that.

As brides or grooms, we should dress up and present ourselves the way we want to on this day but, it should not be at the expense of our health and well being. Remember what this day is about. Your wedding is not about the celebration of the size of your body but about the love between you and your significant other and making a commitment to one another.

What to do Instead of “Sweatin it”

Here are some tips I have developed to use myself and also with my clients who were wedding dress shopping:

  1. Buy a dress that fits you now. Don’t buy something a size smaller. Don’t use words like “my goal size” or “I’ll be pretty when I fit into this.” Fighting your body to go to a size it isn’t meant to be is only going to add more frustration, stress, and sadness. If the person selling you a dress keeps harping on “when you’ll lose weight” or “all brides lose weight” speak up and tell her that isn’t your plan. You do not have to be a victim of diet culture. Buy the dress that makes you feel pretty right now. Also, do not forget that many dresses you try on are just sample dresses. It’s okay if it doesn’t fit perfectly when you try the dress on. The one you get will be tailored to your already beautiful body,
  2. With that, remind yourself of the things that not only make you look beautiful but what makes you feel beautiful. One of my bridal consultants asked me when picking out a dress, “Do you want to feel whimsical? Do you want to feel like a princess? Do you want to be sexy vixen?” Wedding dress shopping became ten times more fun when I could close my eyes and imagine what style of dress would make me feel the most beautiful.
  3. Write down what you want to feel on your wedding day. Write down your hopes and excitements for this day. Think about what memories you want to hold onto.  While the idea of “looking perfect” in your wedding photos may be a strong drive to engage in diet culture, think about what those photos are truly capturing. Most likely, you’ll want to remember this as a day of celebrating love and new beginnings with your partner.
  4. It’s okay to exercise and it is okay to eat. It’s okay to follow your normal routine, As you plan for your wedding continue to follow your intuitive voice. For many people, weddings take months if not years to plan. Do not remove fun foods out of your diet for the sake of just one day. Listen to your body when it comes to exercise. Exercise because you want to give your body the gift of movement, but know it is okay to take days off too. Exercise should not be a punishment to your body.

In Conclusion

You do not need to lose weight for your wedding day. Ultimately, remember what this day means to you and your partner. Your wedding dress should be the accessory to the already amazing you. You know, the person that your partner wants to spend the rest of his or her life with. So, when it comes to “sweatin’ for the wedding,” say, “I don’t.”

LACPA Eating Disorder SIG May 2019

Sheila FormanAlong with the LACPA Mindfulness SIG, the LACPA Eating Disorder SIG is pleased to present:

Title: Mindfulness-Based Eating Awareness Training (MB-EAT): Research and Clinical Application

Date: Friday, May 17th at 10:30 am- 12:30 pm

Location: LACPA Office, 6345 Balboa Blvd, Bldg 2, Suite 126, Encino 91316

Presenter: Sheila H. Forman, PHD (PSY15265) Psychologist and MB-EAT Instructor

Description: Mindfulness-Based Eating Awareness Training (MB-EAT) is an evidence-based treatment protocol for overeaters and binge eaters researched and developed by Dr. Jean Kristeller at Indiana State University. The presentation will explore the basics of MB-EAT and how to apply it in a clinical setting.

Bio: Sheila H. Forman, PHD, CGP is a clinical psychologist, group psychotherapy and qualified MB-EAT (Mindfulness-Based Eating Awareness Training) Instructor in Santa Monica. She is the founder of the TAME Your Appetite: The Art of Mindful Eating program. For more information, go to www.DrSheilaForman.com  or www.TAMEYourAppetite.com.

LACPA ADDRESS and PARKING INSTRUCTIONS:  The buildings are on the south-west corner of Victory and Balboa, and Bldg 2 is the second building from Balboa. If you come from the Westside, take the 405 to the 101 and exit going north on Balboa to just before Victory (park on the street or in the Sepulveda Basin Sports Complex (6201 Balboa Blvd.) on the west side of Balboa, just south of Victory).  Or take the 405 to Victory (past the 101 if you are coming from the Westside) and exit West onto Victory.  Take it to Balboa and turn left, now heading south. On your right, you will see the buildings. Go a bit past the parking lot for the building (we are not allowed to park there during the day), past the Army’s center to the next driveway, which is for the Sepulveda Basin Sports Complex (2nd driveway past the Busway), and park in there. Or park on the street just south of the entrance for the sports complex parking lot. Both sides of Balboa have all day free parking. Allow a 3 – 5 minute walk to the buildings. Walk into the building’s parking area and go to the second building. The LACPA office is right by the entrance off the parking lot, on the left if you walk in from the parking area. Wherever you park, please check the signs

Parking at The Encino Office Park lot between the hours of 9am – 6:30 pm is restricted to building tenants only. We can park there in the evening and on weekends, but not 9 – 6:30 weekdays.

RSVP todrmuhlheim@gmail.com

SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org 

Weight Gain in Bulimia Recovery

by Elisha Carcieri, Ph.D., a former associate therapist at EDTLA

Weight Gain in Bulimia RecoveryOne of the hallmark features of eating disorders is placing a high value on body weight and shape in determining one’s self-worth. In addition, people with eating disorders often believe that body shape and weight can be controlled through diet, exercise, or, in the case of bulimia nervosa, purging. Individuals with bulimia nervosa purge in an attempt to eliminate calories consumed (which is actually ineffective), empty or flatten the stomach, modulate mood, or as a self-imposed negative consequence for binging. Bulimia carries serious mental and medical health risks. The road to recovery from bulimia usually involves (at least) outpatient therapy with a qualified mental health professional such as a psychologist.

Bulimia Treatment

Cognitive behavioral therapy (CBT) is the most well-researched and effective treatment for bulimia. Therapy begins with an initial goal to immediately stop purging, monitoring weight and food intake and implementing regular eating, which usually looks like three meals and two snacks spread out over the course of the day. Over the course of therapy, the patient and therapist address the various factors that keep the eating disorder going including the over-evaluation of weight, shape, and one’s ability to control these factors, dietary restraint and restricting food intake, and mood and anxiety-related factors associated with the eating problem.

Most patients with bulimia nervosa present to treatment at a weight that is in a “normal” range for their height. This is in contrast to those with anorexia nervosa, who are typically underweight. Despite being at a normal weight, the characteristic weight and body dissatisfaction associated with bulimia is strong at the beginning of treatment, and patients believe that they are controlling their weight via their purging behaviors. People with bulimia often restrict food intake in various ways, only to eventually binge and purge. Because treatment involves eating meals at regular intervals without purging, a common fear at the outset of treatment is whether changing eating patterns will result in weight gain. The answer is…maybe.

For most patients with bulimia nervosa, treatment will not result in a significant change in weight. However, some patients may gain weight and a small percentage of patients will lose weight as a result of eliminating binge eating. It is not advisable for patients in recovery from an eating disorder (or anyone, for that matter) to have a specific goal weight in mind. Focusing on weight loss is incompatible with CBT strategies to eat balanced and sustaining meals at regular intervals. Weight may fluctuate over the course of treatment, and, when a person is eating normally, the body naturally gravitates toward a biologically determined weight that is largely out of our control. Indeed, learning to focus less on body weight as a determinant of achievement or self-worth is a valuable treatment goal.

What is Weight Suppression?

Some patients with bulimia may start treatment at a weight that is in the normal range for their height or even on the high side but low in the context of their adult weight history. Weight suppression is maintaining a body weight that is lower than an individual’s highest adult weight. Recent research has begun to shed light on the effects of weight suppression on eating disorders, especially bulimia. Bulimia is often kick-started with a desire to lose weight and attempt at weight loss through dieting. Research has demonstrated that living at a suppressed weight has a significant impact on bulimic behaviors, increasing the likelihood of binge eating (potentially through a brain-based biobehavioral self-preservation mechanism), and subsequently purging. Relatedly, and counterintuitive to what people with bulimia believe about their ability to control their weight, weight suppression is associated with weight gain over time, which further promotes dieting and purging given the strong aversion to weight gain that most sufferers experience.

Will I Gain Weight?

So, what does this mean for treatment and recovery? For patients seeking treatment, this means that yes, you may gain weight, especially if your weight is lower than a previous higher adult weight. This may feel scary, especially at first. Clinicians may even feel uncomfortable having this discussion and feel tempted to reassure patients that they will not gain weight. However, this message is inconsistent with what we now know about weight suppression and reinforces the idea that gaining weight is to be feared and avoided at all costs. Gaining some weight may actually be the key to breaking the cycle of binging and purging, which is much more valuable than maintaining a lower weight.

Greater weight suppression is associated with persistent bulimia symptoms and relapse, so gaining some weight may actually increase the likelihood of recovery from bulimia and also serve as protection against future eating disorder relapse. Weight gain may not just be a side effect of treatment, but it may be an appropriate treatment goal if you have bulimia and are living at a suppressed weight, just as it is an important goal for someone recovering from anorexia.

In Conclusion

If you have had previous treatment, but are still binging and/or purging, it is important to explore whether weight suppression might be a contributing factor. You can discuss whether gaining some weight might be appropriate with your clinician. Understanding the role of weight suppression on maintenance of the eating disorder should serve as motivation to continue treatment and work toward managing negative feelings related to weight gain. Indeed, it is helpful to explore the motivation behind the importance of thinness or maintaining a certain weight and challenging fears associated with gaining weight. You may find that living at a slightly higher weight, once acceptance is achieved, can be much less stressful and time-consuming than forcing your body to weigh less than it is biologically programmed to.

References

Fairburn, C. G. (2008). Cognitive behavior therapy and eating disorders. New York, NY: Guilford.

Juarascio, A., Lantz, E. L., Muratore, A. F., & Lowe, M. R. (2018). Addressing weight suppression to improve treatment outcome for bulimia nervosa. Cognitive and behavioral practice, 25(3), 391-401.

Lowe, M. R., Piers, A. D., & Benson, L. (2018). Weight suppression in eating disorders: a research and conceptual update. Current psychiatry reports, 20(10), 80.

 

Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716). Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she is also a proponent of alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size. She is currently living in Charleston and working as a full-time mom to her two sons, ages 3 and 1. Dr. Carcieri is a member of the Academy for Eating Disorders (AED). She can be reached via email at dr.elishacarcieri@gmail.com.

A Better Resolution For Exercise

joyful movement
Representation Matters

by Kristen Wright, LMFT

Did you make a New Year’s Resolution to start a new fitness routine? Those “thirty days of push-ups or sit-ups” or “do 15 of this and 12 of that a day to your ideal body in no time,” might sound appealing. But you may have already discovered it’s just another commitment that has left you feeling depleted and disheartened. What if this didn’t have to be a failure but the start of a new experience?

No, you are not lazy, inadequate, or hopeless. There! I said it and I firmly believe it. It is very easy to slip into a cycle of unhelpful thoughts. If you were talking to your friend that way, would your friend listen to you? Of course not! Saying “Get off that couch, you lazy cow” is no way to get it done. I used to think beating myself up would help me work out, and I had no excuse for not exercising. I now know that is not the solution.

Here are some strategies that may be helpful.

Rethink Exercise as Simply Movement

Exercise is often viewed as something unpleasant or punishing or even penance for eating. It shouldn’t be! Movement is much broader. It may be a dance class, a walk on the beach with your partner, a hike with a friend, or shooting hoops with your child. It could be jumping around to good music or playing on the ground with our pets or kids. It might even be just walking back and forth or stretching. Workouts come in many forms and all movement counts. Movement should be fun and have some freedom.

We need to reject the idea that a workout has to be 30 minutes to an hour, requires sweat, requires a shower, and must involve so many sets of different things. What if movement didn’t have to be so structured? If you are still trying to understand why workouts are difficult, it may be because in the past you only exercised when you also dieted. I find that many people with a history of repeated dieting have a very negative association to working out. Reframing it as movement helps with removing that association.

Welcome Those Rest Days

Balance is important. Sometimes rest is more important than exercise. Learn to listen to your body and all its needs. You may have had a bad day at work or you may be dehydrated. Everyone needs days off. When taking care of bodies, we have to take care of our mental health. And sometimes the workouts won’t happen. But instead of thinking of “I missed a day, and everything is ruined,” think instead, “Today I took care of my body by resting.”

Stop the Inner Critic

Become aware of your negative thoughts: “I can’t do this; I am lazy; I am a failure. I am too out of shape.” All of these jumbled thoughts weigh us down. We just can’t expect to operate under these conditions. You should talk to your body as you would talk to a friend. And when you do start being kinder to your body, pay attention to the peace and freedom that will follow. Remember: don’t push yourself to the point of negative self-talk. If the negative inner critic pops up, it is time to evaluate the workout and listen to your body.

Challenge Your Perfectionism

Not all workouts will be better than or even equivalent to the last. Watch and challenge that urge to make each bout of exercise more intense or more successful than the previous one. Try to remove performance measures from your exercise. You do not need metrics to measure the success of your movement. Try focusing instead on how your body feels. As well, after having a great week of workouts you might find that the next workout is barely anything. Don’t despair. Your body might be reacting to fatigue, stress, or just screaming for a break. Remember movement is still movement.

Recognize You are not Obligated to Move

In the words of Christy Harrison, MPH, RD, CDN: “Health isn’t a moral obligation, and you don’t owe *anyone* the pursuit of health. Too much of the wellness world is caught up in healthism, and equating our worth to how much we pursue health goals. But the truth is that your value as a person and as a member of society doesn’t lie in whether or not you value your health.” Now how can this apply to you? Your worth as a person does not correlate to your fitness achievements. You are not a moral failure if you don’t exercise. You are not required to exercise!

In Conclusion

You are the only one who can know what your body needs. Different bodies appreciate different activities. Just because your favorite fitness guru on Instagram says that “this” or “that” will get you in shape, does not mean it is something you must do. You are the leader and guru of your own body. So, let your body tell you what it enjoys. Find the movement that makes your body say “Ahah! That felt good, let’s do this again.” It took me many different workout classes and videotapes to find out what I liked. I had to invest and become the explorer and expert of my own body. Be your body’s best friend and explore what your body likes to do. Please don’t give up on a movement style your body enjoys because it doesn’t look like it is making a difference. Rather spend time enjoying how the movement makes you feel. Do you feel better afterward?

AT EDTLA we can help you improve your relationship with food and exercise.

Say Cheese! How to Be in And Celebrate Photos

How to Be in And Celebrate Photos
Photo by rawpixel on Unsplash

In today’s digital age, photos of ourselves are everywhere. For many people with eating disorders and body image issues, they can be a source of distress.

Do you avoid photos? Do you refuse to let people take or post photos of you? Do you hide in the back when asked to be in a group photo? Do you agree to be in them but then feel awful when you see them because you can’t stop critiquing your body? Do you spend hours looking at old photos and longing to look like you used to?

If you relate to any of these scenarios, you are like many of my patients who feel uncomfortable with their bodies and either avoid photos altogether or obsess over them. I’m going to suggest some strategies that have been helpful for my patients.

The first thing to understand is your anxiety is almost always increased by the avoidance of something that is distressing but not dangerous. When a situation makes you anxious, the only way to get over it is to face it. With time, your brain learns to tolerate it—we call this habituation. This means that avoiding photos entirely will just increase your distress.

Next, consider how sad it is to not be photographed. As Alison Slater Tate wrote in her widely-shared article “This Mom Stays in the Picture”, “I’m everywhere in their young lives, and yet I have very few pictures of me with them.” I’ve worked with patients that have so avoided photos there was almost no record of their lives. How sad for the people that love them!

On the other hand, it is also unproductive to take photos and then scrutinize the results for each of your flaws. This kind of obsessive focusing is destructive and only makes people feel worse. It also defeats the purpose of having taken the photo.

Photo Exposure Strategies for Body Image

Here’s what I suggest:

  1. When you look at a photo, resist the urge to zero in on your areas of body concern with an eye to criticize. Instead, look at the image of your entire body more holistically. Try to be nonjudgemental and curious.
  2. Remember that what you are looking at is not actually your body, but a representation of your body. Many factors influence this representation—the lighting, the angles, the quality of the camera, the capability of the photographer. (How many times have you taken a number of photos in a row and the people look different and better or worse from one to another?). If you take enough photos, it’s an inevitability that some will be good and some will be bad.
  3. Think about the purpose of taking the photo. Set aside social media bragging rights—the authentic purpose of a photo is to capture a moment in time, to remind you of a feeling you have experienced, to recall a place that is special to you, or to celebrate a relationship.

Take, for example, a woman who attended her sister’s wedding. When she looked at the photos, she could choose to focus on how unmuscular her arms were, the imperfections in her hair, or how she was bigger than certain other guests. Alternatively, she could focus on why they took the photo: the joy she felt in sharing this special occasion and her love for her sister.

Also, keep in mind that your perception of the same photo can differ over time. How many times have you hated a photo when it was taken but looked back on it later and loved it?

So this is my challenge to you: when given the opportunity to pose for a photo, seize it. When you look at the photo, practice not critiquing your appearance or comparing yourself to others or to past versions of yourself. Instead, ask yourself what is important about the photo—why you took it and what you wanted to remember about the moment it captures.