Categories
Eating Disorders

Managing Holiday Meals with an Eating Disorder

Holiday Eating Disorder
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The holidays are something we should all look forward to and enjoy, but they can be fraught for people with eating disorders. The combination of festive large meals and large gatherings of people who may not be your family of choice, as well as people you have not seen in a while, can be challenging for many people—and can be especially hard for those recovering from an eating disorder. When you eat in contexts different from the ones in which you eat on a daily basis, you naturally face a higher level of challenge. With appropriate pre-planning, it can usually be better managed.

I always suggest having a plan for each upcoming situation. Think through who will be there, what the food environment will be, and how you can best manage it. Try to anticipate how you will navigate the various food situations and the different social challenges. Identify supports ahead of time if you can. Have a plan for navigating diet and body talk. Breathe. Hopefully, the following suggestions will help you come up with your plan.

Managing Food

In many families and traditions, the very design of holiday meals can be a setup for disordered eating. Diet culture only facilitates this. The anticipation of a large meal on the holiday sends many into restriction, sometimes for several days, as they prepare for the holiday meal. They reason that since they are going to eat a lot at this festive meal, they will try to conserve calories—and go into the meal at a deficit. However, this is the opposite of what one should do; it merely becomes a self-fulfilling prophecy. The more one restricts leading up to a holiday meal, the more likely that one will feel out of control at the meal.

Instead, eat regularly leading up to the holiday. Our bodies in most cases will appropriately override attempts at restriction. So, to avoid engaging in your eating disorder at the holiday meal, practice the opposite of restriction: eat regularly scheduled meals and snacks—approximately every three hours—throughout the days preceding the holiday and the day of. If you don’t go into your holiday dinner famished, you will be able to make more logical and appropriate decisions and are more likely to avoid disordered eating behaviors.

Plan ahead to eat a satisfying meal. If you struggle with disordered eating, it can be helpful to think about the meal ahead of time and plan specifically what you are going to eat. Families often follow a similar traditional menu every year—it is not hard to predict the foods that will be served and envision a plate that is satisfying and includes several food groups (starch, protein, vegetable, fruit, dairy, and fat). Plan for dessert as well. Celebrations are part of life. Enjoy them.

If on the other hand, you are not sure what will be on the menu, ask the host so you can plan accordingly. If it is a potluck, bring something you will enjoy and feel comfortable eating.

Challenge all-or-nothing thinking. Be aware of your own black-and-white thoughts about food and challenge them. Many people actively classify their eating behavior as either “being good” or “being bad.” They reason that if they are not restricting or “being good,” they might as well just give up and binge. Try to resist the temptation to either resort to restricting or entirely give up and just binge and then restrict after the holiday. This is a common trap. Just because it is a holiday doesn’t mean you need to engage in eating disorder behaviors. The more you work on regular eating throughout the year, the more present and engaged you’ll be at holiday meals; it becomes just another meal.

Remind yourself that you can eat these foods again: The belief that the holiday is the only time you’ll be able to have these foods reinforces an all-or-nothing mentality. Remind yourself that this type of food, while typical of this special occasion, can be made available on other days. For example, you can also enjoy leftovers the next day. You can even ask for recipes and make some of the special dishes on your own at an entirely different time of year.

Do an initial walkthrough of buffets before getting food: Buffets can be especially overwhelming for those who experience eating disorders and disordered eating. A good strategy is to first survey the buffet without taking any food. You can view all the food and make decisions about what to take without overloading your plate (because inevitably there are great things at the end). For example, choose proteins, some starches, a vegetable, and so on. Make and fill one complete composed plate. Seeing all of the food you intend to eat on the plate at one time will help ensure you are eating enough. Do the same with dessert. Let yourself eat what sounds good and move on.

Accept that it’s normal to indulge on holidays: That is okay and part of the joy of celebrating. If you are uncomfortably full or racked with guilt, sit with the feeling rather than erasing it with more food; most likely it will pass in a few minutes. Holiday meals are a way of connecting with others. Eating more indulgently on occasion is normal and won’t adversely affect your health.

Even if you end up soothing your anger or sadness with food, see it as feedback, not failure. Notice that you binged—and remind yourself that it’s just one meal. Practice self-compassion. The goal when there is a lapse is to learn from it and figure out how you can strengthen your recovery skills.

Managing Triggers

Plan ahead. For those in recovery, it can also be extremely helpful to plan ahead for potentially triggering situations. Think about where you have struggled in the past on holidays or where the challenges might lie and try to identify coping skills you used to navigate similar situations, and how you can practice them over the holiday period.

Practice self-care. Before the meal or in the days leading up, make sure you get some time to yourself and do something that is restorative such as meditating, going for a walk, talking to a support person, and prioritizing sleep. If you’re staying with family for an extended time, ensure you continue to have some downtime and alone time. Bring some comfort items in a soothing kit.

Identify a support person if possible. If you have a partner or friend or any family member who is aware of your eating issues, try to talk to them ahead of time about how they can support you if you get overwhelmed or struggle. You might even create a way of signaling them during the meal.

Managing Social Aspects

Identify potential triggers. You may have anxiety about the people you will see over the holidays. Many people may see friends and relatives they haven’t seen for a while, and you may feel anxious about anticipating judgment about your body, especially if you’ve experienced any recent changes in body size. Try to think through the different scenarios including the worst-case scenario and identify how you can cope if that were to come to pass. Remember that usually, the worst-case scenario does not occur and that the anticipation is often worse than the actual event.

Don’t feel compelled to reeducate others. You may also see relatives and friends who are stuck in diet culture who may make comments that can be triggering. If you feel an anti-diet approach has been personally helpful, you may be eager to share your knowledge with family members. You may want to help release them from their own diet prisons as well as transform them into HAES® advocates and supporters for your health. However, you’re likely not going to be able to proselytize them over the course of a meal or even the holiday period. Not everyone can get on board and breaking away from diet culture is a process that takes time. So set realistic expectations.

Focus on protecting yourself if the conversation turns to diet or body talk. You may not want to directly confront the talk. That’s okay. You may consider simply leaving the table to go to the restroom or gently changing the subject if you feel uncomfortable. It may help to have a conversation starter ready for such a scenario.

If you do choose to address it head-on, you could try saying something like:

  • I’m trying to practice body positivity, or
  • I’m choosing to focus on gratitude this holiday and not depriving myself,
  • I’m working on being more flexible (or not commenting on other people’s bodies).

If someone comments on your own body or eating you could use any of the above strategies or politely respond that you do not wish to talk about your body or that you feel uncomfortable.

When things get tough, try to find some gratitude. If applicable, notice the appreciation you have for being among loved ones and enjoying a meal with people you care about.

If you are supporting a child or other loved one with an eating disorder, we outline strategies that may be helpful.

Categories
College Mental Health Eating Disorders Family based treatment

Eating Disorder College Contracts

If you are sending a young adult with a history of an eating disorder to college (or seminary or another away program), it is a good idea to have a college contract in place. This is our recommendation for young adults with anorexia, bulimia, binge eating disorder, ARFID, and OSFED.

College and living away from home for the first time brings novel stressors and recovery challenges. Any transition can challenge the most stable of recoveries. The freedom and independence can provide a breeding ground for an eating disorder. Your young adult will be eating in an entirely different context than the one they have practiced recovery in. Relapses during college or the first period of independence are not uncommon.

Prior to sending your young adult with an eating disorder off to college or a similar independent experience you will want to ensure that your young adult is ready for the challenge of being away from home. A contract is NOT a substitute for readiness. Read more about our criteria for readiness in our post about college readiness. If you deem them ready, a college contract can be very helpful.

A contract is an agreement between the parents and the student—obviously not a legally binding document. Treatment professionals may help develop the contract or play a role in supporting the contract, but they are not parties thereto. I think about a contract as a safety net rather than something adversarial. Parents are on the side of their young adult—and are merely saying, “We want you to be in college, but we want to ensure that you are healthy enough to stay there in order to fully benefit from the college experience.” They then use the contract to specify the criteria required for the student to stay in college, as well as the consequences if those criteria are not met.

As long as you are paying for some of your young adult’s school or living expenses, you have leverage and can require a contract. I do not advise counting on the school to ensure your young adult stays well. No college, even those with excellent mental and physical health resources, is able to provide the level of oversight that parents do.

A contract should include the following:

  • A minimum healthy weight for your student based on optimal physical and psychological recovery and historic weight patterns, ideally developed with a treatment team and taking into account that young people are expected to gain weight until about age 20
  • A release of information signed by your student, allowing treatment professionals to communicate with you
  • A plan and cadence for your student to get weighed and have their vitals checked
    • Some families are able to set this up with the college health center; others with private practice professionals (MD, RDN, or therapist)
    • The frequency of weighings and vitals will be determined based on length in recovery and stability
  • A plan for consistent communication of the above weights and vitals information (i.e., each time it’s checked, or only if concerning; to whom on the team and when to parents).
  • Recommended treatment follow-up with various professionals. This ideally follows the recommendation of the prior treatment team and may include as many team members as necessary. Some individuals may need a full team; others may just need weights and vitals.
  • An expectation regarding behaviors:
    • Meals—how many meals and snacks the student is expected to have and any associated guidelines, such as a meal plan.
    • Exercise—any appropriate restrictions.
    • Any other behaviors of concern, such as purging
  • The specific steps parents will take if there is a lapse including weight loss or an increase in eating disorder behaviors.
    • For smaller lapses, parents may give the young adult some time to self-correct or regain weight independently and maybe increase sessions with team members before initiating other steps.
    • Some parents specify that they will come to school and stay with the student and try to help them for a time to get on track while staying in school.
    • If these steps are not working and for more significant lapses, parents may require the student to come live at home or go to residential treatment.

As with any consequence, parents should not include anything in the contract on which they are unwilling or unable to follow through.

I recommend that parents and their students start talking about the college contract and college readiness at least six months before the start of college, so the young adult is not surprised by the idea of a contract. I suggest parents write the first draft and then share it with their treatment team and their young adults and then incorporate feedback. The agreement should be signed by the parents and the student and the current treatment team members may also sign it showing their endorsement.

Sample College Contract:

In order for Mary to be successful at college, we agree to all the terms set out in this agreement and will not take action beyond what is prescribed in the agreement without a review with Mary and her team first.

  • We will treat Mary like a responsible adult.
  • We will not show up at college unannounced.
  • We will give 24 hours’ notice before visiting.

In order to remain at college:

  • Mary will be weighed weekly at her counseling sessions with Dr. Freud. Dr. Freud will communicate her weight to her parents each week.
  • Mary will attend weekly counseling sessions with Dr. Freud and bi-weekly appointments with dietitian Nancy.
  • Mary will eat 3 meals in the dining hall and 3 snacks daily containing appropriate amounts of fats, carbs, and protein in order to maintain her weight. She will eat a dessert daily.
  • Mary will not become a vegetarian.
  • Mary will maintain a minimum weight of 140 pounds.
  • If Mary binges/purges, she will discuss it with Dr. Freud and Nancy and develop a plan.
  • Mary agrees that physical and emotional health and safety are a higher priority than educational progress or participation.
  • Mary will be mindful of exercise as a potential trigger and will limit exercise to no more than 3 times a week for 30 minutes. Mary agrees she needs to consume sufficient food to fuel her level of exercise.

The following backup plan is not a punishment but a safety net to facilitate ongoing progress:

  • If Mary’s weight drops below 140 pounds, she has 2 weeks to regain the lost weight. Her parents and dietitian will help with suggestions and provide more snacks.
  • If lost weight is not regained by the 2-week mark, one of her parents will come to college at the end of classes for the week and all meals and snacks will be supervised by her parents for the weekend, even if Mary has to cancel something. Mary can return to classes after the weekend after the Sunday evening snack. Supervised weekends will continue until weight is back above 140 pounds. Once the weight is regained, Mary can remain at school without parental supervision.
  • If supervised weekends do not result in expected weight regain in 2 weeks, Mary will return home until weight is regained.
  • If Mary fails to comply with any of this agreement, she will need to withdraw and either enter residential treatment or seek employment.

We will review this contract at the beginning of each academic semester and revise it as needed to help Mary maintain healthy eating habits.

Signed:______________________                Date:_______________

 

Signed:______________________                Date: _______________

 

 

Witness: ­­­­­­­­­­­­_______________________           Date:­­­­­­­­­­­­­­_______________

Categories
Dieting Eating Disorders Family based treatment teen eating disorder

What Parents of Teens with Eating Disorders Need to Understand About Diet Culture

Body Liberation Photography

 

Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.

It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.

What is Diet Culture?

Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.

Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.

Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.

Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.

We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.

This also applies if your teen has Avoidant Restrictive Food Intake Disorder (ARFID), an eating disorder not typically driven by weight and shape concerns. Diet culture equally impacts people with ARFID.

How to Do This

  • Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
  • Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
  • Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
  • Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
  • Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
  • Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
  • If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
  • Teach your teen to think more critically about health and media messages they observe.
  • Take the Weight Implicit Association Test. Be gentle with yourself and remember we all have weight bias.

It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.

Categories
Eating Disorders Family based treatment

Externalizing an Eating Disorder: When, Why, and How Do You Do That and Who is “Ed” Anyway?

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Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.

Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”

This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.

Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.

When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.

Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.

While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. There is one recent qualitative paper that studied the process of externalizing the eating disorder.

What are some advantages of externalizing the eating disorder?

  • It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
  • It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
  • Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
  • Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
  • It puts everyone on the same team battling a common enemy: the eating disorder.
  • It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.

Reasons you might not want to externalize the eating disorder

Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.

According to the qualitative paper by Voswinkel and colleagues (2021), there were mixed perceptions about externalizing by patients interviewed. Some people with eating disorders feel like the eating disorder is a part of them and felt they were not taken seriously or criticized by externalization. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. People with eating disorders may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.

So, should you do It?

Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.

It is always a good idea to check with the person with the eating disorder about how they perceive externalizing. If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.

Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.

Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.

Categories
Eating Disorders Family based treatment

How do I Parent My Teen During Family-Based Treatment? When to Set Limits

Photo by Jakob Rosen on Unsplash

Parents doing FBT often struggle with “normal parenting concerns” and setting limits while doing FBT. They’re refeeding their teens at home, doing the hard work often done by professional staff at treatment centers, but they still have to parent. It’s exhausting. Their teens who have eating disorders are often experiencing the psychological and physical consequences of malnutrition while also being a teen and facing the challenges that typically come with that stage of life —social and academic pressures, family stresses, desire for more independence, and puberty.

It’s not uncommon for teens to be a little rebellious or to challenge limits. Some parents may feel they should ignore any defiance from teens in recovery or may be afraid to confront behaviors they would normally not tolerate in their children. Other parents may want to clamp down on all undesirable behaviors.

In FBT we talk about separating the child from the eating disorder and joining with and loving your child while waging war against the eating disorder threatening your teen’s life. This model may be helpful in decisions about how to parent. I recommend first trying to determine whether the behaviors you are concerned about are part of the ED or not.

This may not be obvious at first glance, but if defiance or anger or disrespectful language or threatening behavior comes out at, just before, or after meals or during an FBT appointment or a weight check—or around discussions of food, body, the eating disorder, or treatment—assume it’s the eating disorder and not your child. Remember that your child with an eating disorder has a decreased ability to regulate emotions as a result of malnourishment and that they are in a state of terror at these times. This is the fight-or-flight reaction seen during episodes of high anxiety. The eating disorder will make them lash out in hopes of avoiding the source of the anxiety (food, weighing, etc.). During those moments, I recommend speaking to them compassionately and recognizing the underlying emotion of anxiety, and not reprimanding the behavior in the moment.

During times outside of meals or treatment—which may seem few and far between for those just beginning this journey—this behavior is less likely to “be the ED.” At these times, you should parent largely as you would normally do, with the caveat that your child is under increased stress from treatment. If you would normally reprimand or give a consequence to your child for inappropriate language, staying out after curfew, or screaming at you, feel free to do so. You do not have to tolerate rudeness and defiance and can require appropriate behavior.

As you do this, do keep in mind that the intense process of recovery—including exposure to what is often 6 meals per day—is putting your child under additional stress. I like to remind parents that in many cases, teens go to residential treatment centers. While these centers have their pros and cons, one helpful aspect of residential treatment is that it removes the teen from the everyday stresses of school and home life (annoying brother, curious extended family, and heavy academic loads, etc.) so they can focus entirely on treatment.  It can be easy to overlook how these stressors add up.

You might want to pick your battles so your teen doesn’t feel battered all the time. Some smaller things—like clothes on the floor of their room or not cleaning their bathroom—may need to be overlooked. You will want to prioritize addressing behaviors that affect you—for example, rude language—or that interfere with the goals of treatment, including weight gain and normalizing eating. So, if your teen doesn’t come back in time from an outing with friends and misses a snack or meal, that would be a high priority to address. On the other hand, you might choose to let go of their not going to bed on time (as long as it doesn’t keep them from getting up in time for breakfast).

If you are unsure whether the behaviors are part of the eating disorder or not and how to respond, I encourage you to consider whether their behavior is different than it was prior to the eating disorder. A normal developmental trajectory may be contributing to the changes in behavior. An older adolescent may be more challenging of authority and may exhibit behaviors that were not a part of the repertoire 6 to 9 months earlier, before the start of the eating disorder.  If the behavior is different, consider whether it might be related to the stress of recovery, the result of malnutrition, or something else entirely. If it seems different and/or persists, speak to your treatment providers or have your child assessed. It may be that they have another mental health disorder that needs to be addressed. If the behaviors were there before the eating disorder, you should also talk to your treatment providers and see if additional support is needed to help you address them.

Finally, keep in mind that this is a tough time. You have a lot on your plate. Parenting and treating an eating disorder is a lot all at once. Try to separate your teen from their eating disorder and develop a list of priority behaviors to address so you don’t take on too much at once. Talk to your treatment team about your concerns. And remember you don’t have to abdicate all parenting just because you are also on their treatment team.

Recommended Reading

Two of my favorite teen parenting books:

Get Out of My Life, But First Could You Drive Me & Cheryl to the Mall?: A Parent’s Guide to the New Teenager by Anthony E. Wolf

Parenting Teens with Love and Logic: Preparing Adolescents for Responsible Adulthood by Jim Fay and Foster Cline

Categories
Eating Disorders Los Angeles

Low-Cost Eating Disorder Psychotherapy Now Available

We are excited to announce our low-cost eating disorder therapy program. Via our designation as a practicum site we are now able to train advanced graduate students in psychology in evidence-based treatment for eating disorders. This allows us to further our mission of helping to disseminate evidence-based treatments and to bring them to people in California who need them. We are also able to offer a true low-cost treatment option. Our psychology externs will be able to provide individual psychotherapy for adults with bulimia nervosa and binge eating disorder and teens and adults with disordered eating and body image concerns.

Beginning in August, 2021, the cost for sessions with our psychological externs is $60 per therapy hour. Sessions are available in-person in our office in mid-Wilshire area of Los Angeles and virtually with individuals throughout California.

As of June 2021, EDTLA has developed a memorandum of understanding with two local doctoral programs in clinical psychology— the California School of Professional Psychology at Alliant International University and Pepperdine University’s Clinical Psychology Doctoral Program of the Graduate School of Education and Psychology.

Each year, up to two advanced-level doctoral students are carefully selected through an interview process to be psychological externs at EDTLA. Psychological externs provide individual and group therapy to adults and adolescents.

All of the psychological externs receive extensive training through EDTLA’s training seminars and supervision program in order to provide quality therapy at lower fees than is typically found in Los Angeles.

All Psychological Externs work directly under Dr. Muhlheim (PSY15045), meaning that treatment decisions and progress are monitored on a weekly basis by an experienced licensed psychologist.

To inquire about receiving treatment from one of our psychology externs, please complete this form (and put Psychology Extern) under “Requested Clinician.”

You can read more about our current psychology externs here.

Categories
Anxiety Eating Disorders Psychotherapy

EMDR for Eating Disorders

Photo by Amanda Dalbjörn on Unsplash

By Runjhun Pandit, LPCC

EMDR….Sounds scary.

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

Sources

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

Categories
Anxiety Eating Disorders

What’s in Your Soothing/Coping Kit?

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.

Categories
Eating Disorders Evidence-based treatment

Structuring Your Eating Disorder Recovery Environment

 

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.”

Recovery 101

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.

 

Categories
College Mental Health Eating Disorders Uncategorized

College, COVID, and Eating Disorders: What You Need to Know

Photo by engin akyurt on Unsplash

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:

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.

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