Say Cheese! How to Be in And Celebrate Photos

How to Be in And Celebrate Photos [image description: 4 people wearing volunteer shirts taking a selfie]
Photo by rawpixel on Unsplash
In today’s digital age, photos of ourselves are everywhere. For many people with eating disorders and body image issues, they can be a source of distress.

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

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

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

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

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

Photo Exposure Strategies for Body Image

Here’s what I suggest:

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

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

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

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

Breaking The Myth: Men and Eating Disorders

Male Eating Disorders [image description: man looking at his own reflection in jagged shard of a mirror]
Photo by Fares Hamouche on Unsplash

by Carolyn Hersh, LCSW

In the spring of 2018 major league baseball player, Mike Marjama abruptly retired from the sport to focus on being an ambassador for the National Eating Disorders Association. He struggled with an eating disorder growing up and his move to working with NEDA was only to help save lives but to give men who are struggling a voice to hear that they aren’t alone. Mike Marjama is a reminder that eating disorders can affect anyone of any gender.

According to the National Eating Disorders Association, about one in three people with  an eating disorder in the United States are male. That’s roughly about 10 million males. There is a long-standing myth that men do not have eating disorders. A common misconception is that eating disorders are a women’s issue. As a result, many men are ashamed or may not even recognize that they have an eating disorder.

Eating disorders are complex mental illnesses with both genetic and environmental contributing factors. It is also important to be aware that just because someone has poor self image does not necessarily mean they have an eating disorder and vice versa.

Although eating disorders are about much more than body image, it’s hard to ignore the societal impact of cultural ideals of beauty and gender. Women are not the only ones impacted by gender ideals. The ideal male body includes large muscles and little to no body fat. Next to the Cosmopolitan magazines are the men’s magazines with models showing off their six-pack abs. I recall a time shopping with my fiance when we came across the packages for men’s underwear. There, staring me in the face, was a man with a Spartan-like body, doing his best to sell this product. I could see how men could feel intimidated, just like when women are walking through a Victoria’s Secret store. Many males they are taught at a young age to be ‘tough” and “not to cry.” Expressing feelings is often frowned upon.

According to the National Eating Disorders Association, “25% of normal weight males perceive themselves to be underweight and 90% of teenage boys exercised with the goal of bulking up.”  Male athletes can become hypersensitive to their bodies when sports such as running, gymnastics, or wrestling has them paying close attention to their weight. Many males are loathe to ask for help because it may make them appear weak or too feminine The fear might be “I am not man enough.” Unfortunately, health professionals may also not recognize eating disorders in males who are usually diagnosed later in their illness, which can lead to a worse outcome.

Eating disorders in males may look different.

A few years ago there was a reaction to the athletic physique that had been so celebrated. The “dad bod” trend became a thing where it was okay for men to be more round in the middle. But even with this new trend it still puts out a message that there are only certain body types that are acceptable.  What if you are round in the middle and round all over? Is that not okay? And isn’t any guy who is a father technically walking around in a Dad-Bod? It is great that there is more room for different bodies, but we need to expand our acceptance to all shapes and sizes. And not only accept different bodies, but also recognize that the body doesn’t define who someone is as a person.

How can you help a male that you know is struggling with an eating disorder and body image? Just as with females, we need to work on celebrating the men in our lives with what they do and not how they look. We need to let boys know it’s okay to show emotion. It’s okay if they do not look like Superman. Having bulky muscles or not having bulky muscles doesn’t define the strength of a person; especially their character. We need to accept people of all genders and all bodies in all their glorious diversity.  It isn’t about your body that defines you, but who you are as a person. If only people could be more impressed with the contributions we put out there instead of the size of our stomachs. Hopefully, with more men like Mike Marjama coming forward, it will decrease the stigma surrounding this mental illness and more men will seek the appropriate help that they need.

Carolyn Hersh, LCSW and our other therapists are able to work with people of all genders at Eating Disorder Therapy LA.

Source

National Eating Disorder Association

April 2019 LACPA Eating Disorder SIG with Gloria Lucas

Gloria Lucas [image description: photo of Gloria Lucas]Date: Monday, April 8 at 7:30 pm 

Presenter: Gloria Lucas 

Title: Historical Trauma and Modern Day Oppression: How Does This Relate to Eating Disorders?

Description: For the past 30 years, eating disorders have been represented as a white, middle-class phenomenon. Due to the lack of representation of people of color and indigenous populations with troubled eating, these communities suffer from high rates of undiagnosed conditions, inaccessible treatment and culturally insensitive practices within the eating disorder world/community itself. In this presentation, participants will have the ability to evaluate eating disorders through a social justice lens that centers the experiences of people of color and indigenous descent people. Participants will learn about historical trauma and the white-thin-cis-hetero industrial complex. This session will also explore the legacies of colonialism on self-esteem, body-image, and food. Providers will receive guidelines on how to make services more accessible.

Bio: Gloria Lucas is a body-positive activist, punx-feminist, entrepreneur, and a public speaker. In 2014, Gloria started Nalgona Positivity Pride – a Xicana-brown-indigenous body-positive organization that focuses on the link between historical trauma and eating disorders – after personally struggling with an eating disorder. Like the womxn of color that came before, she creates spaces for marginalized folks to support each other and heal from the trauma of colonialism, eurocentric beauty ideals, and disordered eating in communities of color.

Gloria’s work has been featured in the Huffington Post, MiTú , Bitch Magazine, and The Body is not an Apology. She lives in Los Angeles with her boyfriend and their cats, Pepita and Mister Orange.

Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland) or street parking

RSVP to: drmuhlheim@gmail.com

March and April SIG meetings are open to all professionals.   During other months SIG meetings are open to all LACPA members.  Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org

Social Anxiety and Disordered Eating

Social Anxiety and Disordered Eating [image description: people standing around a buffet table]

by Kristen Wright, LMFT

It’s the season for the holiday party…and an endless supply of scrumptious appetizers! It is time to get your small talk on and gather around friends and family to whom you may or may not be interested in talking. It is time for holidays…and anxieties. Maybe you have a tendency to overindulge on all the goodies at the food table? After all, you rarely get a chance to eat these sweets or homemade savories, so might as well. Maybe overeating is your daily habit and something you are not even thinking about. If you have any anxiety about socializing or overeating at a party, then this article is for you. 

A few years ago, I found that I couldn’t stop the snacking and grazing at parties. I would sometimes dread going to a party knowing that I would most likely overindulge on the sweet or savory delights. I would often wonder if people were watching me and taking notice of my extra size portions. It was a compulsive and conscious decision on my part because if I was eating, I didn’t have to worry about talking. I would think to myself, “What will I have in common with the other people at the party?” “What if I don’t have anything to say?” “What if I am not that interesting?” Maybe for you, there are other anxious thoughts: “I don’t want to share about my year.” “I don’t want to be reminded that I am still single.” “I don’t want to have to talk to strangers.”

Sometimes that table of food can be the way out of a dead conversation. If we are snacking at the table, we have a common interest and shared experience, and that common factor is the food. Many times, I would stand by the food table and just comment on the food with the people I was chatting with. And let’s say if I got into a conversation I wasn’t particularly interested in, I could excuse myself to go refill my plate. It became my escape behavior and after several years I realized I needed to address my anxieties and learn to better manage my social anxiety.

Addressing Social Anxiety


I had to develop a new focus when attending social events and parties. Rather than focusing on my discomfort, I started to focus my attention on learning about the other person. I started to find I could actually enjoy having a conversation. I also came to realize that I was becoming more of an explorer with every conversation. That was my new focus, and the other person was unaware of my anxiety or the reason for my probing.  I was just learning how to actively listen to what was being said.  And I became less preoccupied about food.  I found I could focus on the way they talked or perhaps their posture. I heard what they said. I stayed in the conversation and asked questions about what they were saying. It was about being “present” and the first few times were both an experiment and an experience. It was scary at first and I had to push myself. Time went by increasingly faster as I became engrossed in other things besides food. I no longer needed to quell my anxiety by satisfying my taste buds. And, although this helped to get me started, the second phase involved strengthening my hunger and fullness cues.

Addressing the Temptations of an Abundance of Food

There were some other factors that played a role in my overeating at parties and that was what we often refer to here at Eating Disorder Therapy LA as “Diet Mentality.” A lot of times I would go to a party and say, “I couldn’t or shouldn’t eat something.” Or sometimes I was like, “I never have access to these goodies, I might as well eat as many as I can.” This is known as unhelpful all-or-nothing thinking.  We can learn to change our thoughts. Cognitive Behavioral Therapy is a great treatment modality used to change thought patterns of this nature. Learning to find the grey area between all-or-nothing thinking takes work but helps us to avoid overindulging.

Addressing the Over Eating at Parties 

Let’s talk briefly about the actual eating. Yes it will take some conscious planning and preparation to prevent overeating at the party.

If you struggle from overeating at parties, here are some strategies you might try:

  • Eat regular meals and snacks leading up to the party: Many times we try and restrict or skip meals prior to a party in anticipation of eating a lot at the party. This though sets you up to overeat. It is best to eat as regularly as possible.
  • Make it a meal: If the party is during an actual mealtime, then plan to eat what would feel like a meal. If you are planning to eat a meal beforehand, pre-plan that you are having a snack or dessert at the party and recognize your options will be about what really taste good.
  • Scan the table of goodies: Do a survey of the food and make decisions to be selective about what you want rather than just loading up the plate as soon as you get there. When you make your choices of what to eat, taste what appeals to you and eat what tastes good. If something isn’t appealing or satisfying, then you have the freedom to not eat it. At Eating Disorder Therapy LA we work with our clients to help them understand what being and feeling satisfied is about and understanding fullness.
  • It is normal to indulge on holidays: Yes is its! And we need to remind ourselves we can enjoy and practice mindful eating at the same time. Remind yourself as well that you can have these treats again soon, maybe buy them, or have them at another party. That way you won’t fall into the fear that you won’t ever have these foods again and over indulge.
  • Listen to when you get full: It might get a little disappointing to have to stop eating. But be present and mindful that this happens and the feeling will pass in a few minutes.

Recovery When Grieving by Carolyn Hersh, LCSW

Grief and Eating Disorder Recovery [image description: blue butterfly on a leaf]On May 8th, 2017 my mother died due to complications from cancer. It was an unexpected death. I still cannot believe she died. My mom was diagnosed in January and passed away in May. She had gone to the hospital for trouble breathing and never left.

I can clearly remember going back to my childhood home and seeing her sneakers in her room waiting for her to return to them. I cried so hard seeing everything she had touched just days before but left, never to feel her embrace again. I was one of those things she left.

It’s been more than a year now since I lost my mom. It was a year that tested me in so many ways: emotionally, physically, and spiritually. One thing I had to face was how my eating disorder and my longstanding recovery would play out through the worst thing that has ever happened to me.

I have my own history of emotional eating and bulimia nervosa. It started at a young age. Whenever I was sad as a child my mom’s solution to cheer me up was a trip to the bakery for a giant cookie. My emotional eating and my hatred of being the larger kid was just one of many factors that led me to a path of destructive behaviors of binging, purging, and restricting.

I’ve been through enough therapy and treatment that I am able to recognize moments when I find myself starting to eat mindlessly. I check in with what emotions or events are going on. I have, for the most part, overcome being an emotional eater. But, then I was hit with an intensity of emotions that I had never felt before. The seven stages of grief are very real and I definitely went through and felt each of them.

My anger, my sadness, my pleading to bring my mom back, to having brief moments of acceptance washed over me on a daily basis. My sadness felt like someone placed a brick on top of my heart. Trying to breathe became difficult at times. I was angry, intensely angry, at cancer, the doctors, the hospital, at God, at my mother, and at myself. We hear so often how eating disorders fester when we feel a loss of control. Losing my mother was the ultimate reminder “you have absolutely no control over this.”

In the early weeks and even months of living in a world where my mother no longer existed, I wanted comfort and distraction. I wanted food. I wanted alcohol. I wanted anything that would take this pain away. And in those moments of pure sadness, I consumed. I knew full well this wasn’t the way to handle my emotions. I decided I need to reach out to my dietitian because yes, even professionals need tune-ups. I remember sitting in my dietitian’s office crying because I gained weight and was feeling out of control with my body and my feelings. I quickly felt hypocritical as an advocate for all bodies are beautiful and guilty because a weight gain should not be something I should be crying about. I lost my mother. Worse things have occurred other than gaining a few pounds. My dietitian reminded me that I know how to eat and that my body will go back to where it should be when I honor my hunger and satiety cues. But, then she shocked me by saying, “Carolyn, maybe you needed to allow yourself to binge in those moments. So it happened. You binged. It’s done. Now, go back to your real coping skills.”

My dietitian gave me permission to accept my binges. She demonstrated compassion for me when I had no self-compassion. She was right. Sometimes we have to be okay with where we are at. My dietitian did not give me the green light to revert back to maladaptive behaviors. She pushed me back on a path of not beating myself up during a time where the last thing I needed was to hurt myself more.

So, how do you manage recovery in a time of grief?

  • Don’t go back to your eating disorder. Just don’t. You know it won’t help and when you are feeling low why make yourself feel lower? But, if you skip a meal or eat a few extra cookies just know that it is not a relapse. I do not consider my binging moments a relapse. They happened. I engaged and then I stepped away. Be gentle toward yourself and give yourself permission to say “It’s okay it happened. Now, what can I do to get back to my recovery?”
  • Go back to your coping skills. Maybe I could have engaged in binging and purging. Maybe I could have thrown my hands in the air and said: “what’s the point?” But I didn’t. In all honesty, I knew this wasn’t something I wanted. So, I made a list of things for me to do to help me through those really tough moments. I took time off from work and went figure skating with friends. The ice was always a very therapeutic place for me, and just being able to feel that cold air whip across my face me feel happy. I spent time journaling, cuddling with my dog, and reaching out to friends and family when I needed to talk. I began nightly walks with one of my girlfriends where we had heart to hearts. I made self-care a priority. You have to. The small lapses that I fell into never once trumped the real self-care that I was doing for myself. If I had beaten myself up for binges and weight gain then it could have sent me on that spiral back to a full relapse. Self-care may mean forgiving yourself for your lapses. Forgiving myself helped me continue to move forward.
  • Death really sucks. Losing someone you love is painful. It can be a torturous pain. There is no way around that. Losing my mother and thinking about her still to this very moment makes my stomach twist, my heart pound, and my eyes water. There will be bad days. I use a lot of radical acceptance in my grief where I acknowledge this is how it is and I have to figure out now how I continue to live in a world where my mom isn’t calling me. It’s hard to do. Believe me, there are days I do not want to accept this, but if I have to pull from my DBT workbook, acting the opposite is what gets me through the rough days. I don’t want to accept my mother is gone, but that is the reality. I do not, however, have to forget her and how she has impacted my life.
  • It’s okay to cry. It’s okay to feel whatever it is you are feeling and it is okay if those feelings come and go in minutes or if they last for days. There is no wrong way to grieve. During my grief I went to Nashville for a vacation, I would go out on weekends with friends and laugh, and I eventually moved to California. I managed to feel happy on some holidays and cried on others. I did not stop living, but I allowed for my grief to take space in my life.

In the end, going back to my eating disorder would just have caused more chaos in an already chaotic time in my life. I know it won’t give me control, it won’t make me happy, and it certainly will not bring my mother back. I have this blue butterfly pendant necklace my mom bought me before I went into an intensive outpatient program. It gave me strength then and I wear it now to continue to remind myself that my mother was every bit a part of my recovery and is every bit still a part of me. Now, why would I want to throw all that away?

Carolyn Hersh is available to see patients with eating disorders and has Saturday hours. Contact us for more information. 323-743-1122 or lmuhlheim@eatingdisordertherapyla.com 

LACPA ED SIG December 2018 Event

Kym Piekunka [image description: photo of Kym Piekunka]Date: Tuesday, December 4th at 7:30 pm 

Presenter: Kym Piekunka

Title: Eating Disorders and the Impact on Siblings

Description: Kym Piekunka will present on the unique impact eating disorders have on siblings. While many studies have focused on how sisters and brothers affect recovery outcomes, Kym co-created an online sibling survey with Bridget Whitlow, LMFT, to better understand their experience and support needs. With 274 responses from five countries, specific themes have emerged. Come join us as Kym reviews these findings and utilizes her story to highlight the importance of supporting this population.

Bio: Since her sister Kacy’s death in 2002 from bulimia, Kym Piekunka became a speaker, blogger, and advocate focusing on her sister’s experience. Over a decade later, Kym observed the reality for siblings had not progressed. Sisters and brothers were sidenotes in articles, organizational education, conferences and treatment, so Kym switched gears. In 2017 she made it her mission to give the sibling experience a voice by creating the website KymAdvocates.com. Recognizing the lack of research and support systems surrounding siblings and the eating disorder impact, she co-created an online sibling survey. Currently, Kym is presenting on data results, expanding the survey in other languages, and developing sibling support systems.

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland) or street parking

RSVP to:  drmuhlheim@gmail.com

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

 

This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

Fear Food [image description: woman in witch hat holding bowl of halloween candy]For teens with eating disorders, Halloween can be scary for the wrong reason: the candy! Most teens with eating disorders are only willing to eat a restricted range of foods. Expanding this range is an important goal of treatment, with the reintroduction of fear foods being a key step. Candy tends to be high on the fear food lists of many teens.

Halloween presents an ideal opportunity for families who are working with an FBT approach.

A Taste of Recovery

Most teens in America are excited for Halloween and its bounty of candy. By incorporating some candy during your teen’s Halloween week you can help them approximate the lives of teens who do not have eating disorders. This step can give them a taste of the full life you want for them—a life where they are unencumbered by food restrictions, a life where they can enjoy all foods, a life where they can travel the world confident that they will easily be able to meet their nutritional needs, and a life where they won’t feel the need to shun social events for fear of facing the foods there.

I know that I’m painting a beautiful picture and that this is easier said than done. Teens with eating disorders will deny that the disorder is driving their food preferences. Instead, they claim they simply don’t like candy anymore. Or that candy was the preference of a child and since then their palates have matured. But don’t believe them—you have crucial parental memory and knowledge. You know which foods your teen actually liked a few years back. You also probably know the foods on which he or she binged if they binged. And it is not credible that any teen really hates all candy!

Especially if your teen had a great many fear foods, you may already have experience reintroducing some of them. But once meals start going more smoothly, some weight has been restored, and binges and purges have subsided, many parents are reluctant to push further. Why rock the boat when your teen seems to be doing well? You may be wondering: Is candy really necessary?

In fact, this Halloween is exactly the right time to introduce candy.

Exposure

It is much easier to introduce fear foods before your teen is completely independent in their eating. Right now, you are still overseeing meals and your teen does not yet have their independent life back. Pushing the issue of fear foods becomes more challenging when your teen has regained most of their freedom.

When you introduce fear foods to your teen, you will probably feel anxious. Your teen will too. You may even feel like you are going back a step. This is how exposure works—it is supposed to raise your teen’s anxiety. When your teen avoids these fear foods, their anxiety decreases, reinforcing the avoidant behavior and justifying the anxiety response. This perpetuates both the emotion and the behavior. But the food is not truly dangerous—if the teen were to eat the food, they would learn that nothing catastrophic happens. In exposure, the teen is required to eat the food, and the anxiety response shows itself to be baseless. With repeated exposure, the brain habituates, learns that the food is not harmful, and loses the anxiety response.

Exposure works through repetition over a sustained period of time—not all at once. It’s likely that each food on your teen’s feared list will need to be presented several times before the thought of eating it no longer causes extreme anxiety.

You may feel that requiring your teen to eat candy is extreme. However, remember: the healthy part of your teen probably wants to eat candy, but the eating disorder would beat them up if they ate it willingly. By requiring your teen to eat candy, you are actually granting your teen permission to eat it—permission they are unable to grant themselves. After recovery, many teens report that they really wanted the fear food but were too afraid—it was only when their parents made them eat it that they were able to.

And I would argue that fearlessness in the face of candy is important for your child. So be brave about facing potentially increased resistance by your teen and model facing your own fear.

Here’s How to Incorporate Candy During Halloween:

  1. Choose a few types of candy based on your teen’s preferences about three years before they developed their eating disorder. (If you can’t remember, ask one of their siblings or just pick a few options, maybe one chocolate-based and a non-chocolate alternative.) Make your choice based on providing your teen with the typical American teen experience. (American teens will typically collect a lot of candy on Halloween, have a few pieces that night, and then have candy as snacks a few times during the following week.)
  2. You may choose to tell your teen about the candy ahead of time or not. Some families find that telling teens about exposure to fear foods ahead of time is helpful; other families find that it is better to just present a fear food without warning. But note that you are not required to ask their permission; FBT is a parent-driven treatment.
  3. Serve a single serving of candy during dessert or snack a few times during the week of Halloween. Plan carefully and be thoughtful. Do this with the same resolve that you use when you serve them any starches or proteins. You may want to introduce the candy on a day when you feel more confident, will have more time to manage potential resistance, or can be sure a second caregiver will be present. You may not want to present candy, or any fear food, before an event that you are not willing to miss in case you encounter an extreme reaction.
  4. If your teen binges or purges, make sure to sit with them for an hour after they eat the candy.
  5. Plan for what will happen if your teen refuses to eat the candy. For example, will you offer something else instead and try the candy again tomorrow? Offer a reward for eating the candy? Create a consequence for noncompletion? Whatever you decide, be consistent and follow through.

If you do this-this year, there is a good chance that by next Halloween your teen will be eating candy independently!

August 2018 LACPA Eating Disorder SIG Event

Jaye Azoff, Psy.D., Los Angeles [image description: photo of Jaye Azoff]Date: Wednesday, August 22nd at 7:30 pm

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

Description: Recovery from anorexia nervosa (AN) follows an unpredictable, windy path. Rarely does it come quick; there is no single trajectory, no infallible indicators of how a treatment will play out. Opinions about the recovery process vary, depending on whose perspective is being sought. The patient—the former patient—sees it one way—but there is no guarantee that the opinions of others, therapists, partners, loved ones, will concur.

This talk addresses the question in a unique fashion. A patient: a former patient, (a doctoral level psychologist) will share her account of a treatment that unfolded over roughly twenty years.

Several points will be discussed. Importantly, the former patient will consider 1) briefly, the etiology of her illness (and we will assume a basic understanding of eating disorders here); 2) briefly, how (some) of the various treatments were directed and integrated across the multi-disciplinary teams (and throughout the years) 3) how her protests and resistances—and there were many— were met, and with what explanations 4) most importantly, looking back, what aspects of this treatment are now recalled as influential, elements seen in a positive light, elements perceived as detrimental.

Perhaps most important for the purposes of this discussion is the concept of the “power struggle” – that all too familiar war our patients learn over years of treatment with us to get into with themselves which then becomes acted out with their caregivers. How can we as treaters do better at not engaging, and shift the power and responsibility back into their hands?

Namely, how can we teach them that if they are to get well, it will be because they choose to get well? How do we teach them that they “win” nothing by restricting their snack for an evening or vomiting their dinner because they feel hurt over something we as clinicians might have said or done to them? These are complicated constructs, but not impossible ones, and by using Dr. Azoff’s past as a case vignette, we might be able to chisel away at some of the answers.

Bio: Jaye Azoff, Psy.D., has been practicing in the fields of clinical psychology and neuropsychology since 2008, when she graduated from the California School of Professional Psychology in Los Angeles, where she trained under the Health Emphasis Track. Dr. Azoff did most of her field training at Children’s Hospital Los Angeles’ Keck School of Medicine, where she practiced in the hematology/oncology neural tumors unit and trained in many roles over nearly eight years, eventually advancing to become the team’s neuropsychology fellow. It was Dr. Azoff’s own recovery from an eating disorder that propelled her forward and launched her into the eating disorders field. Currently, she is an eating disorders consultant, and she is the owner and operator of Basik Concierge, the world’s only boutique concierge firm offering wraparound services for individuals with eating disorders and their families. She is also the In-House Clinical Consultant for the Kantor and Kantor law firm, which fervently works to attain treatment for individuals with eating disorders struggling to gain access to care. Dr. Azoff is a past board member of the Eating Disorders Coalition. She is a sought-after speaker, having formally addressed the United States Congress in the Spring of 2013, and travels nationally to speak to patients and families affected by eating disorders, as well as delivers in-services to clinicians and other individuals eager to learn about various topics related to eating disorders. 

Location:  The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 245, Los Angeles) – free parking in the lot (enter on Highland)

RSVP to:  drmuhlheim@gmail.com

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

On Buying Bigger Clothes: The Tale of Nana and Her New Shoes

buying bigger clothes [image description: photo of my grandmother walking through a shoe store with her walker]buying bigger clothes [image description: my grandmother walking through shoe store with her walker]Recently, I went to visit my grandmother, who is almost 103 years old.  She was complaining of leg pain. She asked me to help her put on her shoes.  I tried really hard.  But in her sweltering apartment (she can’t stand any temperature below 80), I was sweating and the shoes were not going on.  I had visions of Cinderella’s stepsister needing to cut off her heels to get her feet into her shoes.

Nana has edema—swelling in the lower part of her legs—because she has been sitting in a wheelchair a lot lately.  She is quite fashionable and still loves to get dressed up every day.  But no shoes were fitting.

I had to nearly drag her, but I convinced her to go shoe shopping with me. When we went to the shoe warehouse, we pushed her in her wheelchair but brought along her walker as well.  Nana has always worn a size 7, but we could not fit her into any shoes smaller than an 8.5 or 9!  We tried on one pair of gold shoes —Size 9.  Finally, we were finding some shoes that fit.

Nana loved them.  And she found them comfortable. The woman who had insisted on wheelchairing everywhere, refusing to walk, suddenly started walking with her walker and refused to stop!  She was not taking off those shoes and she was not going to ride in the wheelchair again.  Suddenly, Nana was transformed.  Not only was she comfortable, but she felt stylish.

Why am I telling this story? Often when I am working with patients of any size who have eating disorders, they may have gained weight from a previous lower weight that the eating disorder was an attempt to maintain.  People often experience a sense of failure and surprise when their clothing size goes up a level, just like Nana did. This is no surprise:  our culture overvalues thinness.  But continuing to wear too small clothing is uncomfortable physically and mentally.

People often have a lot of reasons for not shopping for larger clothing —they worry they will be unable to handle the anxiety and sense of failure, and they also don’t want to spend the money on a larger size.  I had to help Nana face this.  She didn’t totally understand why her shoes didn’t fit, she felt disappointed, and she definitely didn’t want to spend any money. But boy, after she got those shoes on, she felt so much better!

My patients tell me the same thing —once they have clothes that fit well and are stylish, they feel more able to face the world, and getting dressed each morning is no longer an occasion for self-deprecation.

Bodies age and change in ways that we can’t control.  We need to accept that.  My advice is always to buy a few things that fit you well and help you to feel great and put the other clothes out of sight for now.

And when I spoke to Nana last week, she let me know how much she was loving her gold shoes and walking more again!

Are We Setting Recovery Weights Too Low?

 

[image description: a rusty scale]At the recent International Conference on Eating Disorders in Chicago, I attended a plenary, Recovery from an Eating Disorder: How Do We Define It? What Does It Look Like? And Should It Always be the Focus? During this plenary, Anna Bardone-Cone, PhD spoke about the essential components of recovery from an eating disorder. She indicated that definitions of recovery should include the following three domains and proposed the following criteria for each domain of eating disorder recovery:

  • Physical — defined as BMI greater than 18.5
  • Behavioral— defined as absence of any binge eating, vomiting, laxative use, or fasting within the past 3 months
  • Cognitive — defined as EDE-Q subscales within 1 standard deviation of age-matched community norms.

Hold on a second—the weight criterion used to define recovery from anorexia nervosa in most studies is a BMI of only 18.5?

Most in the full plenary room agreed that for anorexia nervosa recovery, a BMI of 18.5 is too low a criterion to declare all people recovered. I agree with Laura Collins Lyster-Mensh, who made the following tweets:

  • Isn’t it possible that by setting target weights at the low end of the tail we are holding patients in chronic mental illness.
  • Setting low, population-based weight targets for ALL EATING DISORDERS means weight suppression and malnourishment and prevents psychiatric recovery for all but those who are genetically designed to be in smaller bodies, IMO.

I totally agree. If we now acknowledge that anorexia can occur in people of higher weights—a phenomenon often, and problematically, called “Atypical Anorexia”—then shouldn’t a BMI target as low as 18.5 be abandoned in favor of individualized recovery weights?

In fact, weight suppression researcher Michael Lowe was present at the plenary.  During the Q&A he proposed that rather than using a categorical definition of weight recovery (a single BMI number) we should use a continuum—for example, the recovered patient’s BMI relative to their pre-illness BMI.

How Are Recovery Weights Established?

Unfortunately, there is very little consensus on how to determine whether a patient with a restrictive eating disorder is at a recovered or healthy weight. This affects research and practice. If researchers define recovery based on an 18.5 BMI and this weight is really too low for many people with anorexia, what does this mean for the research studies? For one thing, in clinical trials a lower percentage of people would be deemed “recovered”, showing our treatments to be even less successful than we believe them to be.

But it has bigger implications for the potential for patients to truly recover. If we set recovery weights higher, maybe more people will be treated to full recovery. Setting the BMI bar so low means we’re not insisting on full weight recovery for all people. As Laura Collins points out, the effect of this is that only those who are privileged enough to be in genetically smaller bodies may ever actually reach recovery.

And what are the ramifications for practitioners? There may not yet be an established way to determine a recovery weight—consequently, many patients may never recover. If we acknowledge that gaining to a healthy body weight is a prerequisite for full psychological recovery, then we are dooming many people in larger bodies to a life of purgatory in which they remain insufficiently sick to need intensive treatment, but never achieve full recovery.

In one recent paper, Jocelyn Lebow, Leslie A. Sim, and Erin C. Accurso survey 113 child and adolescent eating disorder treatment providers inquiring about the methods used to determine weight restoration in clinical practice. Their findings show:

  • 40.7% of practitioners used growth curve data
  • the remaining (nearly 60%) employed a diverse range of approaches
  • providers who specialize in Family-Based Treatment were significantly more likely to use an individualized approach versus considering adolescent preference

Lebow and colleagues concluded that:

Although there is a modicum of endorsement for using growth curves to predict expected body weight, this is not universal practice and is inconsistent with methods used in treatment studies. The lack of an evidence-based method to calculate expected body weight—or even a best practice consensus for calculating this number—is a major oversight in the field that requires empirical attention.

Why Might Providers Set Recovery Weights Too Low?

What are some of the reasons providers might be setting recovery weights too low?

  • No empirical consensus or guidelines on how to set target weight
  • Lack of available growth records data to determine an individualized recovery weight
  • Financial limitations—insurance companies reduce costs by lower treatment limits, which are facilitated by lower weight goals
  • Client resistance—pushing for higher weights requires overcoming greater resistance and anxiety from the patient and sometimes family over higher weights.
  • Weight stigma—even treatment providers may be susceptible to society’s war on obesity, and consequently may err on the side of under-restoring a teen in recovery.

Over twitter, one mother responded to my conference tweets about an 18.5 BMI recovery goal as being too low and tweeted the following:

  • We need all professionals to understand the need for higher recovery weights. Recovery is about state not weight. So many parents know this but are stuck with uneducated team members who undermine their work.
  • If professionals consider a return to pre-eating disorder growth patterns for height and weight to be weight restoration, we parents are saying wrong. Eating disorder voices are very loud at this weight. We recommend an additional 10% for the first few years of recovery at least. This quiets the eating disorder voice and patients are more likely to stay recovered.
  • I want all current professionals worldwide to understand this. There are so many parents in our international group whose professionals are not getting it. Maybe it has not been studied officially but anecdotally we are seeing this in high numbers. 
  • If it’s not part of their training, providers should at least listen to and support parents in this. We are committed to our kids’ recovery every bit as they are. 
  • It takes parents a while to get it too. It’s frustrating for professionals when parents undermine. I was horrified at the first proposed recovery weight and was afraid of my child being made fat. But I got educated pretty quickly, opened my eyes and realized I needed to take it further in order to achieve full recovery.

Stephanie Zerwas, Ph.D. (not at the conference) chimed in over Twitter and asked the parent:

  • What language helped you as a parent to “get it? Parents often have a belief that being a little underweight can help their child not worry about weight gain, not realizing that it keeps kids stuck in limbo and hypervigilant.

The parent responded:

  • What helped us parents “get it” was seeing those in our support group brave enough to take their kids to higher weights reporting their kids’ eating disorder voices finally quiet down. We keep repeating state, not weight = recovery and realized goal weights are set mostly too low 
  • Too many parents are upset that eating disorder professionals are saying their kids are recovered and not listening to them when they say their kids are still vulnerable, using behaviors, and need to be a higher weight. This is the power of parent groups. We know this needs to change. 
  • Parents also not understanding weight restoration is a moving target. They come to our group stating their child is weight restored and still struggling and often clinging to a weight goal given years ago. There is no “Weight Restored” in eating disorder recovery only “state restored.” 
  • We are seeing this extra 10% to be effective in many of our children who still struggle with eating disorder behaviors at 100% pre-illness percentile of growth. In the meantime, if patients are still struggling and parents want this, we should be supported. But yes, bring on the studies!!

What Do Parents Say About Recovery Weights?

So, believing that parents do indeed know their children best and are an untapped resource to study this further, I took to Twitter to ask parents to share their experiences about recovery weights being set too low. I got an overwhelming response. Below are some excerpts of what parents sent to me:

  • At her lowest weight, our daughter was BMI of 21.9. Our doctor told us “she is not at an anorexic weight.” She is currently BMI 31.6. We felt she was finally starting to shift her thinking when she was at around a BMI of 29.5.
  • When my daughter was 17, she lost 25 pounds. At her lowest, her BMI never fell below 20. Yet she was extremely ill. After she had regained about 14 pounds, her period returned, but her “state” was still awful. She is now in a range of BMI 25.5 to 26. The difference this last 5 pounds has made had been amazing. Her level of insight and flexibility is much higher. Amazingly, the higher her weight, the happier she is with herself and her body. Reflecting back, I am grateful that no one told us she was “recovered” when she got her period back. She needed to get and stay back up to the 80 to 85%ile as per her personal growth curve. At the age of 19.75 she grew another .25 inch. If that isn’t proof she needed more weight, I don’t know what is! I hear so many stories in our group of parents being told to stop refeeding too early. Teams are generally not comfortable pushing weights back up to or above personal growth curves. We are lucky our team was an exception! In our online support group, we have seen time and time again that higher weights make a difference. And the extra weight generally comes with little risk.
  • My daughter was diagnosed at the age of 10.5 with anorexia. The original goal was to get my daughter at a BMI of 15.5 to a BMI of 18. In the next 2.5 years my daughter needed 6000 calories a day and a very high fat diet. She grew nearly 9 inches, went through full puberty, and doubled her initial body weight. Once her growth slowed and her metabolism went down and stabilized, we were able to get her weight up to around a BMI of 22 and that is when we saw TRUE RECOVERY begin. She began to eat “extra.” She began to ask for things. She began to be able to eat independently. Over the last 4 years she has put on around 20 to 25 pounds on her own, naturally. Her BMI is now around 24 – 25 and she is in a 100% solid recovery. She eats intuitively, independently, and reports being free of the eating disorder voice. Fats, high calories, and a MUCH higher weight were essential to getting our daughter into recovery. If I would have listened to the “experts” I believe she would still be struggling.  
  • My daughter was 24.2 BMI at 13 years old when she started exercising excessively and then restricting. She lost a quarter of her body weight in 7 months and our new pediatrician told her to gain 10 pounds and come back in 6 weeks. We fed her 6 times for a total of 4000 calories a day. She finally got her period at BMI 21.8 and within a few months, her anxiety was high and the team suggested it was time to start exercising. My online support group spent a long time helping me understand my own fat phobia and really worked to help me set a higher target weight. My daughter grew another three inches. She is now BMI 23.5 and this is the healthiest I have ever seen her. If I had listened to the specialists, she would be just as sick as she was before.  
  • At her lowest weight and her sickest, my daughter’s BMI was 19.3. We saw improvements in her state once she was over 25 BMI and in the “overweight” range. Had I allowed a reduction in her food intake at 23 BMI when it was suggested to me, my daughter would have been in a perpetual eating disorder purgatory.
  • My daughter’s current BMI is 24.6. Lower than that or increasing muscle over fat, it is as if her body goes into ‘starvation mode’ and she gets all silly and cranky and her period is delayed.
  • My son was given a target BMI of 19 by his clinician. This was not from a growth chart, it was from a generic BMI chart. My son was still very unwell at that BMI. Thoughts were very strong, and the desire to restrict was high. He was living a half-life, tormented with the anorexia. He was throwing away his lunch and manipulating weight. His clinician was adamant that he did not need more weight, and did not need more food, although I could see he was actually starving. She would not support me to take his weight higher or increase his meal plan. My online support group warned me that this was a common mistake with clinicians. I got my son (with great difficulty, after the clinician had insisted lower was okay), to a BMI of 24. We have never looked back. We have our kid back, he is 16 years old, he is in very strong recovery for some time now. I know the extra weight is what he needed to see recovery. He is living a normal teen life now, is happy and fully functional. We are into year 3 now, and he still needs 3 meals and 2 snacks per day of at least 4000 calories to stay in recovery. We owe our son’s recovery to the wonderful advice from parents that had been in our situation before us. They knew from other parents before them that a generic BMI figure is not recovery. Recovery is a state and not a weight. It makes perfect sense too. After all we do not expect everybody to have the same shoe size.  
  • My daughter was diagnosed approximately 18 months ago with Atypical Anorexia and was very unwell at a BMI of 19. I joined a support group just prior to her entering into treatment. In large part due to the anecdotal advice and experience of others in the group, I was of the firm belief that we needed to weight restore my girl to her own individual weight, not to a particular BMI or any particular upper number. Fortunately, our team was happy for me to take the lead with this approach, and we encouraged weight gain to wherever her behaviors began to abate and her weight settled naturally on its own, with NO reduction in intake. This ended up being at a BMI of around 26, which I do not believe most clinicians would encourage. However, I truly do have my happy girl back and I do not regret any one of those extra kilos. Her body has settled at a weight at which her mind is very well. I believe that if we had been given an upper number that she couldn’t go above, that we would have trapped her in her anorexia needlessly for so much longer.
  • My daughter did not seem to actually begin true recovery until she was at 23.5 BMI.  This was higher than the professionals in her life seemed comfortable with, but I proceeded with semi-confidence (having seen the results of higher weights in other patients, through their carers’ stories) and was never challenged.  Before this higher BMI she struggled so much with ED thoughts and behaviors – very little could get through to her…. therapy, talking, coaching, none was very helpful… only FOOD, in larger amounts that some professionals recommend (specifically with regards to fats – avocados, ghee/butter, olive oil).  At 23.5 something seemed to just “lift”.  She began to be able to participate for herself. She still had many ED behaviors and thoughts, but could push them aside much of the time.  She lost most of her body image issues, and began asking for food outside of the meal plan – especially things she used to enjoy (chocolate, etc.).  Unbelievably, she began asking for MORE food. Consensus among carers in the groups seems to be that 22-25 BMI is where most sufferers see true strides in recovery.  It is very, very rare that BMI under 22 is successful, at least when polled on the peer-to-peer carer support groups.  Most often, it seems as though 23-24 is the “sweet spot” for many.  My daughter has remained at this BMI (just shy of 24) for almost 6 months.

Summary of Recovery BMI

One online support group did their own survey: ” at what BMI did you see real recovery?”

Here are the responses ( note that most were given a target bmi of 19 by their clinician, and had to fight against that, or had to walk away from their provider to get their child into recovery)

BMI 21-22      4

BMI 22            3

BMI 22-23      4

BMI 23            1

BMI 23-34      5

BMI 24            4

BMI 24-25      4

BMI 25            4

So out of 29 respondents,  none got their kid into recovery at BMI 19 OR 20.

A Survey For Parents

We conducted a survey for parents and I’m pleased to share that the first of our parent papers is here. You can also read the press release here.

Sources

Jocelyn Lebow, Leslie A. Sim & Erin C. Accurso (2017): Is there clinical consensus in defining weight restoration for adolescents with anorexia nervosa?, Eating Disorders, DOI: 10.1080/10640266.2017.1388664