EMDR therapy, these acronyms make it sound like a scary treatment intervention. And oftentimes, when I mention this to my clients, they feel scared or confused. They do have questions about how it works and how it is different from hypnosis.
Eye Movement Desensitization and Reprocessing (EMDR) is a treatment specifically created to help people deal with a traumatic situation. It was initially developed for veterans who suffered flashbacks and nightmares upon return from war and were trying to readjust back to life with their families. Soldiers experienced reenactment of the wars in their dreams, emotional outbursts leading to frequent conflicts with their families, inability to maintain steady relationships, and dissociation from reality. EMDR hence was developed by Francine Shapiro, Ph.D. with the assumption that eye movements could assist in desensitizing to a traumatic situation.
The limbic system in our brain is responsible for our behavioral and emotional responses while the brainstem and cortex are the areas that help in relaying the message from the spinal cord to the brain and store the verbal story of the events in our daily lives. When a person experiences a traumatic situation–like an accident or exposure to prolonged emotional distress like abuse or neglect– the usual coping mechanism that would help the person effectively “process” the situation, goes into overdrive. And the limbic system isolates this memory and stores it in the form of an emotional and physical sensation. Due to this isolation, the cerebral cortex doesn’t remember the “story” but the limbic system sends out an emotional response when some events in the present trigger some areas of the traumatic event. Hence, even if the memory is forgotten, the emotions attached to the memory– like pain, anxiety, or body sensations– continue to trigger the person in the present. This prevents a person from experiencing new situations or from living in the moment since oftentimes some parts of the present emotionally burden the limbic system.
During EMDR sessions, the therapist creates a treatment plan and simulates eye movements similar to the ones that occur during REM sleep by asking the client to follow their fingers. Our brain has the natural capacity to heal itself. During the session, the therapist might also use a light bar to help you track the light across the visual field. These movements last for a minute and the therapist will ask you to report any experience–such as a change in emotions,, memories, or thoughts–after each set of eye movements. By repeating this process, the traumatic memory eventually loses its emotional charge and gets stored in the mind instead as a neutral memory. Frequently, people also have smaller memories associated with the actual traumatic memory which also may get resolved along the way. It has been noted that the “healing” of these smaller memories also creates a noticeable change in a person’s life.
Although EMDR was developed for Post Traumatic Stress Disorder (PTSD), growing evidence shows that it may also be helpful for the resolution of panic attacks, anxiety, depression, eating disorders, and negative body image. EMDR helps clients process the traumatic memory and assimilate it in a healthier way without an emotional charge. Studies have shown that EMDR can be used in conjunction with Family-Based Treatment (FBT) or Cognitive-Behavioral Treatment (CBT) since these treatments focus on the here and now of the eating behavior while EMDR focuses on the past experiences around body image or food that maintain the disordered eating behaviors. Research has shown that EMDR generates a connection between body, emotions, and cognitions by allowing the elaboration of traumatic events and simultaneously resolving the emotional blocks attached to the traumatic memories.
A complete EMDR treatment helps the person to “walk through” previously considered traumatic events with greater emotional and impulse control which eventually leads to an increase in feelings of self-worth and self-esteem.
Runjhun Pandit, LPCC is available to see adolescents for EMDR via telehealth. EMDR can be helpful for food-related traumas and other traumas that might perpetuate eating disorder symptoms such as bullying, body shame, and other invalidating experiences. To make an appointment with Runjhun Pandit, complete this form.
Bloomgarden A, Calogero RM. A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. Eating Disorders: The Journal of Treatment and Prevention. 2008; 16(5): 418–427.
Maria Zaccagnino, Cristina Civilotti, Martina Cussino, Chiara Callerame and Isabel Fernandez (February 1st 2017). EMDR in Anorexia Nervosa: From a Theoretical Framework to the Treatment Guidelines, Eating Disorders – A Paradigm of the Biopsychosocial Model of Illness, Ignacio Jauregui-Lobera, IntechOpen, DOI: 10.5772/65695. Available from: https://www.intechopen.com/books/eating-disorders-a-paradigm-of-the-biopsychosocial-model-of-illness/emdr-in-anorexia-nervosa-from-a-theoretical-framework-to-the-treatment-guidelines
Verardo A, Zaccagnino M, Lauretti G. Clinical applications in the context of attachment: the role of EMDR. Clinical applications in the context of attachment: the role of EMDR. Infanzia e Adolescenza. 2014; 13: 172–184
There’s an eating disorder that often gets overlooked amongst the better-known eating disorders like Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder that can involve difficulty tolerating certain foods due to textures, tastes, or smells. It can also manifest as avoidant behaviors stemming from a trauma around food such as choking or getting sick from eating a particular food. Some people worry about whether they are going to be able to swallow food or they have an aversion to throwing up. ARFID can present as a lack of interest in food altogether.
This eating disorder can result in very limited food selections which in turn can lead to medical complications such as low weight, failure to gain weight during childhood, developmental delays, malnutrition, and vitamin and mineral deficiencies. Many people who struggle with this disorder share how uncomfortable it is to eat out socially and feel isolated from peers and family. It can be a very frustrating disorder for the individual who has it and certainly can be difficult for the caregiver or loved ones supporting a person struggling with ARFID. Many people who have ARFID do want to eat. Unlike people with anorexia nervosa and bulimia nervosa, people with ARFID usually do not have fears of weight gain or their body changing.
It can be hard to sit across the table from someone you love and see them unable to feed themselves even when they are hungry. It can be hard to understand and relate to a person with ARFID’s lack of interest in eating or fears that arise around certain foods. Many times caregivers find themselves accommodating meal times by cooking specifically for their person with ARFID or having to plan out exactly what foods will be available to eat when away from the home.
How do you support the person you love as they are trying to recover from this eating disorder?
First off, validation. The recovery process can be really hard. For many people with ARFID doing food exposures is an important element of treatment. This means they are trying foods that they have been terrified of eating or practicing eating to prove their fears are not coming to fruition. It is a scary process to face these fears. They may feel anxious and overwhelmed. Let them know that what they are feeling is real. Validate their feelings. Acknowledge how tough this must be for them, and share that you believe they can do it.
Second, have patience. ARFID is often seen in children but can last well into adulthood. Many of my own clients have been restrictive eaters since they were babies and toddlers. For years families have found ways to feed them and that often involved negotiating with what they would eat and sticking to these safe foods. You may have found yourself making separate meals for your family member and not going to certain restaurants because you knew there were no food options for them to eat. As your loved one begins to do exposure work with foods it will take time for them to become more comfortable. You may want to say, “Just eat” or get frustrated by their continued refusal. Remember that expanding their food variety is a slow process. Pressure and anger are not helpful. In fact, they may be shaming. Encourage your loved one to practice trying new foods every day. Remind them the more they practice the easier this will become.
The third thing that is helpful is allowing them to have agency when it comes to their food choices. People are more likely to try foods that they are interested in versus feeling compelled to eat a food when they do not want to or are not willing to try it. The process can feel less intimidating. As a parent, you may find yourself in less of a power struggle with your child if in the past they have held up strong resistance to tasting new foods.
Fourth is education and support. It can be very powerful to learn about ARFID and its symptoms. It may also be helpful to reach out to other caregivers who have gone through this process. Many parents feel helpless when their child refuses to eat. Having support from a therapist, support group, and medical providers can feel empowering and also help relieve some of the burdens you may be placing on yourself.
If you or someone you know is struggling to eat due to aversions or fears there is help available. Checking in with your medical professional first can be a good place to find out if your loved one is under-weight, has deficiencies from lack of nutrition, or is experiencing any other health complications. At Eating Disorder Therapy LA, I and other therapists have been trained in helping ARFID patients recover. There is hope–and recovery from this diagnosis is very possible.
We are seeing more and more need for treatment for Avoidant Restrictive Intake Disorder (ARFID). Several of our clinicians have several years of experience in treating ARFID and have undergone training in CBT-AR with Drs Thomas and Eddy, the developers of CBT-AR.
The patients we see with ARFID are usually relieved to find treatment that is tailored to them. They report not knowing other people with ARFID and not having people in their lives who understand what it is like to live with ARFID. They report feeling like they don’t fit in in other eating disorder recovery and support spaces.
So, here we have it, a space just for adults with ARFID. Open to anyone in California, age 18 and up with ARFID. Come for support and education.
Group will be held online on Thursday evenings, 5 to 6 pm. Call 323-743-1122 or email firstname.lastname@example.org to reserve a spot.
Clockwise starting at left: adult coloring book and colored pencils, Kinetic Sand (in purple), Enso Buddha Board, scented candle (my favorite—Thymes Kimono Rose), Spek magnetic balls (in purple), good old fashioned Silly Putty, The Squeeze Aromatherapy Dough (in Lavender).
We all deal with stress and have to find ways to cope with a range of emotions. Having ways to release stress, distract, soothe, discharge energy, and fidget can help. Whether you are young or old, managing your own stress or supporting a family member, everyone could benefit from a homemade calming toolkit. Here are a few items that are in my toolbox. What’s in yours?
Other ideas for soothing activities could be cuddling with a pet, doing a meditation, listening to calming music, playing Words with Friends, putting essential oil or scented lotion on your arms. What works for each person will be different. Be creative.
For a long time I was embarrassed to tell people that I was a figure skater. I was afraid that someone would look at me and laugh at the idea that someone like me skated. I felt this way because I am in a larger body and have always been. Even though I loved to ice skate, I somehow knew that I was not in the ideal body for this sport. It never occurred to me back then that these thoughts and beliefs were biases that I had been taught both implicitly and explicitly.
Biases are preconceived ideas about something or someone. They can be negative or positive but often we associate biases as negative. For me, I grew up with the bias that “real figure skaters” were in small slender bodies. I only saw petite tiny women (and girls) glide across the ice when I would watch the Olympics or National Championships. I never saw an ice skater that looked like me.
In my personal experience as an ice skater I can remember a dance and ice skating store shop owner looking down at me as she said, “we don’t carry your size.” I had coaches that reminded me that I’d skate faster if I was smaller and applauded me when I lost weight. I was highly aware that some coaches weighed their students and told them what they could and could not eat. It is really no surprise that in the sport of figure skating there are increased rates of eating disorders and overexercise, and many skaters experience poor relationships to food and body.
I was surrounded by weight stigma as I was teased by kids at school for being fat. It definitely reinforced the belief that my body was wrong. Fortunately I had friends and family who didn’t judge me and supported my passion for skating. Regardless of my size I was a real figure skater. I wore the sparkly dresses. I could do difficult jumps and all types of spins. I competed in competitions and even took home a few medals and trophies. I learned to ice dance with a partner. I performed in ice shows and represented my college at the Intercollegiate Nationals three times. I even took home a silver medal for my event. Eventually I would go on to teach others to skate. I was in love with this sport and I guess in some ways I pushed some invisible boundaries by not succumbing to the negative messages about whether I belonged on the ice or not.
Biases can be so harmful because they create this belief that the size of your body cannot do a certain sport, wear a certain piece of clothing, or just feel like you don’t belong. It was not until I was into my coaching career that I truly saw how our biases could stand in the way of doing something that could be fun. I had two students who changed the way I saw what someone can or cannot do.
The first was a 60 year old man who wanted to learn how to ice skate so he could skate with his grandson who was a hockey player. He shared that he was diagnosed with Parkinson’s disease and wanted to ice skate with his grandson before the disease progressed enough that he wouldn’t be able to do difficult physical activity like ice skating. He told me his left leg was already significantly weaker than his right leg, but he wanted to try so that he could surprise his grandson.
The second student was an eight year old boy who was on the autistic spectrum. His parents wanted him to learn to ice skate because his father was a hockey player and wanted to be able to ice skate with his son. Unfortunately, this student’s autism was severe enough that he would never be able to play on an ice hockey team or join in an ice skating class with others his age. Our one on one lessons focused on just teaching him to stand on the ice, feeling the cold ice with his bare hands, and marching his feet.
If we listen to what society says about only one type of body being right we might miss out on something pretty incredible. Too often in my work as a therapist I hear clients say they can’t do something because their body doesn’t fit the expectations of what has been deemed normal by society. My two ice skating students were people who many might presume were unable to ice skate because of their bodies. They did not struggle with weight stigma, but stigma around disabilities. Many coaches did not want to teach them because they felt it would be too hard to work with them. For me, it was a blessing.
I wish there was more representation of different types of bodies in figure skating and in all sports for that matter. I hope that we can tear down these negative fat biases and that more people in bigger bodies get the opportunity to do the things they wish. Maybe some things need to be modified and maybe you won’t be an Olympic champion, but body size should not be a limiting factor of what one is allowed to do. Think about how your own biases prevent you from doing something.
I am no longer ashamed to tell people I was a figure skater. I am proud to share about my ice skating experiences and the jumps and spins I was able to do. I do not care if there is judgement because figure skating is hard. I bet most people couldn’t do a flying camel spin into a sit spin combination. But, I could, and I deserve to show that off.
In August, 2014, a Los Angeles psychologist who was in the process of taking the licensing exam reached out to me and asked to schedule a meeting. She was interested in pursuing more training and work in the field of eating disorders. We met and there was an immediate recognition that we were aligned. She practiced in the same way I did and had a passion for evidence-based treatment of eating disorders. We discovered we even used all the same patient education materials. And she was an early proponent of Health at Every Size ®. She wanted to know if she could work with me in my practice, but I had no plan to start a group practice. I told this therapist—Dr. Elisha Carcieri—to keep in touch as she completed her licensing.
But I was intrigued, and I didn’t want to lose the opportunity to work with such a capable colleague. So the wheels started to turn. Very soon, I decided to start a group so I could hire her. In December I emailed her back, “I’m starting to think about expanding my practice if you are at all interested… .”And in December, 2014, the seeds of Eating Disorder Therapy LA were planted.
It took time to bloom—because of various family obligations and credentialing issues, Dr. Carcieri finally joined the practice in October 2015. She was well-liked by patients and colleagues alike and we worked really well together, collaborating on other projects as well. After a year and a half with EDTLA, her family moved to South Carolina and she had to leave the practice. Since then, we have continued to grow and add wonderful new colleagues, but I grieved the loss of the colleague who was there at the beginning.
Fast forward to 2020 and the growth of telehealth. I am really excited to share that Dr. Elisha Carcieri is back—joining us via telehealth and will be seeing California patients. She has immediate openings for early morning appointments.
Grief can be complicated and a painful process. This holiday season many of us are experiencing the loss of the past year we were supposed to have. For those who have lost someone special this can compound the difficulty of this years’ holiday season. 2020 has not been easy for many of us and finding joy during the holiday season may feel challenging.
Many years ago when I was first starting out as a therapist I was seeing a client for grief counseling. This client shared with me something I had never heard about. They discussed that when you find a dime it is a sign the person you’ve lost is reaching out to you. It is a sign they are with you. This client told me how they had been finding dimes all over the place. That evening, after having met with that client as I was packing up to go home, I looked down by my chair and noticed a dime.
This concept was not lost on me years later after my own mother died. I would find dimes all the time and kept each one that I found. In a grief support group that I was in many of the group members shared about the signs they received from their loved ones. Some talked about coins they found, some said it was a certain type of bird they’d see, and for others a certain song that came on the radio. What I learned was that it did not really matter what the thing was but how that thing we found kept us connected to the person we love. It brought comfort. It brought peace. It brought healing.
It is okay if you are not spiritual or religious. A sign doesn’t have to signify anything more than a memory or a feeling of connection to that person. Right before Thanksgiving this year my brother sent me a picture of a sweater he saw at a yard sale. It was adorned with carousel horses. My mother was obsessed with and collected all types of carousel horses. In that instant I had goosebumps. “She’s with you,” I said. And he agreed. “I feel it,” he said. “It is nice to think she is here with me.”
Coincidentally, my mom also collected dimes that she found as she believed they were messages from relatives and friends she had lost in her life. I didn’t know this until my dad told me after I shared with him about my new coin collection. Knowing this was something my mom also did made finding a shiny dime even more special. It really makes me feel like she is with me.
Losing someone you love can be difficult. Finding ways to stay connected through a sign is one way to ease the pain and bring comfort to your aching heart. During this holiday season, if you are struggling with the loss of a loved one think about something that connects you to them. Is there a holiday tradition you use to do together or a song you both sang? Maybe there was a food that was enjoyed together that you could make now. Whatever it may be, know that this could potentially help with healing from the loss you feel during this holiday time or during any time of the year.
If you have an eating disorder, or your child has one, there is a good chance that weight gain will be an essential part of the recovery process. This is true not just for people in objectively small bodies, but also for people in larger bodies who are diagnosed with Atypical Anorexia, a weight-biased diagnostic category included in the DSM-5. It is even true for people recovering from bulimia nervosa and binge eating disorder.
The eating disorders field lacks consensus on how to set recovery weights. I know a respected professional who argues adolescents should be routinely restored only up to the 25th percentile weight for age. They argue that this reduces their potential for experiencing weight stigma and reduces their anxiety. However, I see a problem with this, as do many of my colleagues and many families and recovered people.
This article discusses why weight recovery is a priority; what the research on weight suppression says; how we use growth curves in setting recovery weights; what evidence suggests that many providers set recovery weights too low; and how this applies to people in larger bodies.
Why Prioritize Weight Recovery
We know that while weight recovery in anorexia is not sufficient for recovery in and of itself, it appears to be a prerequisite for full psychological recovery. Eating disorder cognitions as well as most of the physical symptoms appear to recede only with full weight restoration. Food is medicine not just for the body, but for the brain as well. That is why we often say, “Food is medicine.”
The research on timelines for eating disorder recovery show that remission of eating disorder behaviors such as binge eating and purging takes an average of eight or nine months, and weight recovery takes on average 12 months. But it takes even longer to end eating disorder thoughts, including the preoccupation with shape and weight and urges to restrict, purge, or exercise. These thoughts can persist for nearly a year after a person has reached a normal weight, has stopped engaging in behaviors, or both.
Weight Suppression and Negative Energy Balance
We also know that weight suppression—defined in adults as the difference between a person’s current weight and their previous higher adult weight—predicts continuation of eating disorder symptoms including binge eating. In children and adolescents, weight suppression would be defined as a negative deviation from one’s expected weight curve (more on growth curves below). Therefore, at EDTLA we prioritize full weight restoration for all patients in all body sizes and with all eating disorders. Failing to fully restore a person to their recovery weight for body and brain could prevent them from a full recovery.
A negative energy balance—taking in less energy than one’s body needs—may be a primary contributor to the development of an eating disorder in someone who has the innate susceptibility. Cindy Bulik, Ph.D. describes how a negative energy balance lowers anxiety for a person with this vulnerability, creating a trap. Restriction becomes seductive under these conditions. Couple this with the evidence that the weight loss leading to the development of anorexia nervosa could be unintentional—such as a side effect of an illness or an overexpenditure of energy for sports combined with undereating. Together these suggest the best defense against relapse is maintaining an adequate energy balance and a healthy weight where the brain is functioning well enough to not act on residual thoughts.
Using Growth Curves to Estimate Recovery Weights
In this section, I will discuss why using individual growth records is so important. We have received guidance from our colleagues specializing in adolescent medicine and eating disorders. Like many eating disorder dietitians, one of the things we do is look at childhood growth records when they are available. This method is more tailored than using population averages such as BMI to set recovery goals.
In the US, most pediatricians and family medicine doctors document children’s growth on the CDC growth chart, which plots height, weight, and body mass index (BMI) against age-based averages. In healthy children and teens, height and weight each increase along a consistent growth curve. Some children and teens grow steadily along the 95th percentile, some along the 75th percentile, some along the 50th percentile, and still others along the 25thh percentile.
But not every body is the same, and it’s normal for individuals’ height and weight to follow different growth curves. For some children and teens, a weight along the 75th percentile and height on the 25th percentile is normal. This defines the growth curves for that individual. Just as not every woman of average height wears a size 8 shoe, not everyone of average height is meant to be at the 50th percentile for weight. There is always a normal distribution in a population. These growth percentages appear to be largely genetically determined.
A deviation on an individual’s growth curve for weight, height, or BMI—even in the absence of actual weight loss—may indicate there is a problem such as an eating disorder. A child should be growing and gaining weight during this time, so the failure of a child or teen to gain the appropriate weight can be equivalent to weight loss. This means that when there is actual weight loss, the amount of suppression—the difference between current weight and where one should be on a growth trajectory—is usually even greater than the actual pounds lost.
Thus, a parent may come to us and say, “My child has only lost 10 pounds.” However, when that weight is plotted and we notice that the child also failed to gain any weight in the months before they lost weight, we might now look at their curve and see that in fact, the child should gain 20 pounds (or more!) to catch up to where they should be on their own unique growth curve. Some kids may not have lost any weight at all—but have fallen short of their appropriate gain for so long that they now should gain at least 10 pounds.
This is why we also often say that weight is a moving target. To remain in recovery, a year from now an individual’s goal weight must be higher than the weight that would be healthy at their age today. And this is true even for children who are no longer getting taller, as it is normal for weight to continue to be gained through about age 20.
Please be aware that some non-ED specialist pediatricians/health professionals may not be well-informed about this individualized process of setting goal weights. I once had a pediatrician who told a teen’s parents she would be happy if my patient got to a certain weight because that was the weight that the pediatrician—who was herself quite petite—had weighed at the patient’s age.
What? A pediatrician setting a goal weight for a patient based on her own unique growth history!?? When you take your clothes in for alterations, does the tailor cut the clothes to fit the tailor? Do you see the problem here?
Speaking of growth curves, the use of growth curves to spot early eating disorders is an underutilized practice. In a recent study on pediatric patients hospitalized with an eating disorder, 48% of patients experienced a deviation in the growth curve a median of almost 10 months prior to the first eating disorder symptoms being reported by parents.
We will also show you how your teen’s weight should be tracking on the weight curve. Teens generally gain 30 to 40 pounds in the course of puberty. While many children gain weight and grow naturally during this period, we find that children who have had an eating disorder may need continuing guidance to help their weight keep pace with their age and height. We encourage parents to keep an eye on their teen’s weight to make sure weight continues to track along the expected curve. We respect parents and educate them on this.
At EDTLA, we do our best to challenge our own weight biases and that of our patients and their families. We believe that facing the anxiety of a patient or a child restoring to a slightly higher weight has benefits that outweigh the costs. We help the family challenge the belief that being fat is worse than remaining ill. I never want to be the provider who set a goal weight so low that it contributed to prolonging a mental illness from which it may take a patient 9 to 22 years to recover.
Challenging weight bias and setting higher weights goals does not always make us popular. Teens with eating disorders are by definition, terrified of gaining weight. In her blog, eating disorder specialist pediatrician Julie O’Toole discusses the setting of goal weights and how parents fear that too much weight gain will make their teen more depressed and anxious. Dr. O’Toole emphasizes the importance of basing treatment goals on data rather than placating the eating disorder.
Remember that an irrational fear of weight gain is often a symptom of the disorder. The anxiety over one’s body size often improves significantly with recovery, which requires more regular eating patterns and—ironically—weight gain. Please note this is rarely immediate. It may take up to a year of being at one’s healthy weight and learning to tolerate a changed body before the eating disorder thoughts fully subside. On the other hand, appeasing the fear of gaining more weight can maintain the fear and potentially the disorder.
How Does This Apply to People in Bigger Bodies?
We are often asked why a person who has historically been at a higher-than-average body weight must be returned to a weight that is higher than average. We recognize that bodies naturally come in a variety of shapes and sizes. Some people are meant to be larger. We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed. We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery. And the research on weight suppression supports this. In the words of Julie O’Toole, “Rarely can a child who is genetically programmed to be larger than average be safely held at a ‘thin’ body weight. Size acceptance may be a part of the family’s treatment challenge.”
Of Course, Recovery is About More Than Weight
Remember, though, that an estimated recovery weight is just that—the best estimate of where recovery will occur. I think it is important for parents to have a roadmap and to know generally whether they might be needing to add (at least) 10 pounds or 20 pounds or 40 pounds because it gives you a realistic expectation of how long the weight recovery phase may take. Again, this may change over time and our estimates are usually a minimum weight and bodies may go higher.
Ultimately, recovery is about state, not weight. And recovery means more than just weight recovery. We are looking for recovery of physical health—normalization of heart rate, blood pressure, and body temperature and resumption of menses when appropriate—as well as psychological recovery which includes improved mood, decreased eating disorder thoughts, return of normal hunger cues, and more regular eating, a less fraught relationship with food, improved social functioning, and a return of interest in other age-appropriate activities.
In one informal survey of 29 parents whose teens were given a recovery goal of 19 BMI, most reported recovery actually occurred at a BMI of 23 or greater and none achieved recovery at a BMI lower than 21. Parents will report that often, with an additional ten extra pounds, their teens were more likely to attain state recovery. If someone is not doing well at what we initially estimated to be a recovery weight, we will review that and may suggest after a few months that we raise the goal weight a little.
This post has described our thinking, which is informed by research, parent feedback, and expert opinions by leaders in the intersection of adolescent eating disorders, FBT, and Health at Every Size ®. We hope it helps you understand our recommendations.
But you don’t have to take our word for it. We invite you to do your own research. Below we’ve compiled some resources from leaders and colleagues in the field. And we strongly suggest you watch this video by Eva Musby.
Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.
Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.
Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”
As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.
In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.
In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.
The Challenge of Environment
In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.
We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:
Having friends or relatives over for dinner
Eating at a close friend’s house
Eating at a restaurant where individual entrees are served
Eating at a family-style restaurant
Eating at a buffet.
Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.
Take it Slow
Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.
More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:
Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
Cooking for oneself
Going to unfamiliar restaurants
Eating at a small-plates, buffet, or family-style restaurant
Foreign travel to countries where the foods may be entirely unfamiliar
Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:
Having meals planned out for the entire week
Eating meals at regular times
Regular grocery shopping
Having a backup plan (in case you run late or a plan changes)
Always carrying snacks (and backup snacks)
Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
Limiting meals at unfamiliar restaurants
Only bringing into the home small quantities of foods on which you have binged
Having a support person you can call
Structured schedules for every day of the week, including weekends
Careful planning ahead (with your team if you have one) for any situation you have not yet practiced
Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.
When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.
As I’ve talked about in depth here, the transition to college away from home is challenging for most young adults. It is especially fraught for young adults with eating disorders. In that article I provided a College Readiness Checklist for students who are either considering their first move away from home after a history of an eating disorder or returning to college after being diagnosed with an eating disorder. I have learned the hard way. I’ve witnessed the heartbreaking reality of what can happen to students who go away before they’re ready. I may seem stringent, but we’re talking about one of the most deadly mental illnesses and this is your child’s life and future.
I was recently asked whether the same standards should apply in the current climate. I replied that I thought the standards should actually be more stringent given the pandemic. This has been on my mind all summer; now, I am prepared to sound the alarm.
Students with eating disorders of all types—anorexia nervosa, bulimia nervosa, binge eating disorder, and avoidant restrictive food intake disorder (ARFID)—often have a narrow range of foods they are comfortable eating. They often struggle with flexibility.
The pandemic has thrown a wrench—really, a whole toolbox—into the college experience. Among the changes this fall is that most dining halls have pivoted to prepackaged meals. This will be an added challenge for students with eating disorders. Students have already reported that the results are long lines as they wait for food, far fewer food choices, no option to portion their meals themselves, and no option to mix and match. These prepackaged meals may be insufficient in nutrients or energy, especially for students in recovery who have high energy needs.
Add to this the experience of students who are quarantining either due to outbreak or exposure, or as required by the college upon return to campus as a preventative measure. Most are in dorm rooms without access to a kitchen. Social media has exploded with unfortunate food stories:
Meals comprising things students cannot eat—a vegan student who gets a steak and cheese salad; a student allergic to gluten who gets a sandwich on wheat bread
Meals never received, received several hours late, or 3 daily meals batched into one delivery at the end of the day.
These stories are garnering attention, people find it laughable, and the colleges are receiving criticism, but I can only think about how the students with eating disorders are impacted.
Eating disorder recovery requires eating at regular intervals and meals sufficient to maintain recovery. Even a small negative energy balance can increase the risk for relapse in individuals with anorexia nervosa or increase the risk of binge eating for those with bulimia nervosa or binge eating disorder.
Students who are not very stable in their recovery may not be able to handle the current climate. They may not be able to seek additional food if portions are too small. People early in recovery often experience shame about hunger. It could be very triggering to receive portions that are not satisfying. Patients with eating disorders may not be able to advocate for their nutritional needs or do the problem-solving required to make sure the meals are sufficient. Finally, receiving an entire day’s worth of meals at the end of the day would be a natural trigger for those who have struggled with binge eating—or for most people!
Add to this the stress of academics and social issues and the uncertainty about the rest of the semester, and you have a perfect storm for relapse.
If you have any doubts about whether your student may be ready for college under these challenging circumstances, I strongly encourage you to consider keeping them home this semester. If there ever was a time to err on the side of caution, it is now.
With most classes online and social options at college significantly limited, this provides a unique opportunity to keep them home so they have more recovery time under their belt before they have to face such eating challenges. They will not be missing much, and you can work on strengthening recovery so that when the pandemic is over they can return as a healthier student capable of embracing the full college experience. You can use my article—which outlines steps to prepare a student for the challenges of navigating recovery in college— to make sure they are fully prepared when the time is right.