Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.
Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.
Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”
As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.
In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.
In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.
The Challenge of Environment
In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.
We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:
Having friends or relatives over for dinner
Eating at a close friend’s house
Eating at a restaurant where individual entrees are served
Eating at a family-style restaurant
Eating at a buffet.
Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.
Take it Slow
Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.
More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:
Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
Cooking for oneself
Going to unfamiliar restaurants
Eating at a small-plates, buffet, or family-style restaurant
Foreign travel to countries where the foods may be entirely unfamiliar
Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:
Having meals planned out for the entire week
Eating meals at regular times
Regular grocery shopping
Having a backup plan (in case you run late or a plan changes)
Always carrying snacks (and backup snacks)
Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
Limiting meals at unfamiliar restaurants
Only bringing into the home small quantities of foods on which you have binged
Having a support person you can call
Structured schedules for every day of the week, including weekends
Careful planning ahead (with your team if you have one) for any situation you have not yet practiced
Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.
When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.
When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.
FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.
While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.
I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder. Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.
So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:
They did FBT on their own, with no therapeutic support
They had meals with their child, but that the therapist met primarily with the adolescent alone
They didn’t supervise all meals because their child resisted it.
In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.
Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.
Signs Your Child Received FBT
Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?
My therapist refers to and acknowledges the three phases of FBT:
Phase 1 —full parental control
Phase 2 — a gradual return of control to the teen
Phase 3 —establishing healthy independence
My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
My therapist adheres to the five principles of FBT:
I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
If my child has been exercising excessively, I was told to prevent this.
After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
I was told it was important to be direct with my teen about eating adequate amounts of food.
My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.
Dead giveaways your child did not get FBT
Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:
I have been told that we, the parents, had caused the eating disorder.
My therapist spends the majority of therapy time alone with the teen.
My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
A dietitian has met alone with my teen and given him or her nutritional recommendations.
My child has been given a meal plan.
I have been told that it is an option to not supervise all meals or prevent all purging.
The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
My child has been in charge of making his or her own meals from the outset of treatment.
In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.
“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media. Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.
This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.
Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.
Three Things I really like about the film:
I love that Dr. Beckham says, “There is never one cause.” This is true.
I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
I love that it shows a male and an African-American with eating disorders.
Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.
Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.
Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.
Truth #7: Genes and environment play important roles in the development of eating disorders.
Truth #8: Genes alone do not predict who will develop eating disorders.
Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.
Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.
Both cognitive behavioral therapy for eating disorders CBT-E, and interpersonal therapy (IPT) are effective treatments for bulimia nervosa, binge eating disorder, and patterns of disordered eating that don’t meet criteria for diagnosis. CBT for eating disorders involves making changes to patterns of behavior and thinking that serve to maintain the vicious cycle of eating disorders. Most people who undergo these therapies get better in response to treatment and continue to improve after treatment has ended. However, for some clients, the emotional and mood regulatory components of binge eating and/or purging represent a significant part of what keeps their eating disorder going.
According to the affect regulation theory of eating disorders, negative emotions such as anxiety, sadness, and anger precede episodes of binge eating, and individuals engage in binge eating in order to distract from or reduce negative affect or aversive emotions. Behaviors such as laxative use and vomiting may be used to ease anxiety about weight gain as a consequence to overeating. Clients often describe having a difficult time identifying, expressing, and tolerating emotions (especially negative emotions), and the disordered eating behaviors are described as providing some relief, numbing, or outlet. The binge eating and/or purging provide a temporary escape from negative emotions. Unfortunately, the vicious eating disorder cycle continues, as the escape is brief and usually followed by feelings of failure, guilt, and shame.
Dialectical behavioral therapy (DBT) was developed by Marsha Linehan for the treatment of borderline personality disorder, a mental health disorder characterized by emotion dysregulation and risk for self-harm and suicidal behaviors. DBT is influenced and incorporates both cognitive behavioral strategies and mindfulness/zen-based strategies. Inherent to DBT is the notion of practicing both acceptance of the client and their current behaviors and circumstances, and confidence in the client’s ability to make change through the use of adaptive skills.
In its standard form, DBT is delivered with multiple components: individual therapy, group skills training, telephone coaching, and a weekly consultation group for the therapists to provide support and ensure quality delivery of the therapy. We find that comprehensive DBT is often an excellent complement to FBT for adolescents. DBT skills include mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. DBT also focuses on behavior through the use of “chain analysis,” which involves reviewing problem behaviors (binging and purging), prompting events, vulnerability factors, and actions, thoughts, or feelings that eventually led to the problem behavior. Clients also identify skillful solutions to the problem behavior, consequences of the behavior, as well as plans to reduce the behavior in the future. The flexibility in thinking that is characteristic of DBT acts in appropriate opposition to the patterns of black and white, or all-or-nothing, thinking that is so common among clients with eating disorders.
There is an adapted form of DBT developed specifically for the treatment of eating disorders that combines the individual therapy and skills training components. DBT skills in and of themselves can also be taught and incorporated into other treatment plans. DBT skills provide valuable lessons, not only for eating disorder sufferers, but also for anyone looking to improve their quality of life.
The following are the DBT skills relevant to the treatment of eating disorders:
Mindfulness – The skills of mindfulness are essential to DBT. These skills foster focusing one’s attention and mind in the present moment, without judgment and acknowledging that the moment is fluid and ever-changing. Bringing awareness to what is going on within our bodies and minds as well as outside of ourselves. Binge eating is considered a mindless behavior that is improved with an increase in awareness of thoughts, emotions, and bodily sensations that occur before, during, and after eating, binging, and/or purging, or while having the urge to do so.
Example: Mindful eating – Clients are guided through the process of slowly and deliberately eating a raisin while observing, describing and participating fully in the experience. This practice is encouraged during meal times as eating mindfully acts in opposition to the loss of control and mindlessness that is characteristic of binge eating.
Emotion Regulation – Enhancing control of emotions through identifying and naming emotions, reducing and managing negative emotions, accepting and increasing resilience to extreme negative emotions, and increasing positive emotional experiences. These skills encourage the use of coping strategies other than binge eating.
Example: Loving your emotion – Based on the principle that mindfulness encourages accepting the entire range of emotions and that one can reduce suffering by avoiding resistance of emotions. During guided meditation clients practice bringing awareness to their emotional experience with radical acceptance, no matter what their emotional experience may be in the moment. Acceptance and love of all emotional experiences eventually reduces the tendency to escape or regulate these emotional experiences through binging or purging.
Distress Tolerance – Sometimes situations or circumstances cannot be changed. Distress tolerance involves learning to tolerate negative emotions or crisis situations without responding in unhelpful ways, such as binging or purging.
Example: Half Smiling – Based on experimental evidence showing that our facial expressions communicate with our brains and have an effect on our inner experience, this skill teaches facilitating inner acceptance by adopting a facial expression consistent with acceptance, the half-smile.
DBT skills are best learned with the guidance of an experienced therapist. They take commitment and practice, but the benefits are far-reaching. If you are suffering from an eating disorder, don’t hesitate to seek help. There are effective therapies out there!
Linehan, M. M. (2014). DBT® skills training manual. Guilford Publications.
Polivy, J., & Herman, C. P. (1993). Etiology of binge eating: Psychological mechanisms.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. Guilford Press.
I have two amazing speakers lined up for August and September. It’s early in the LACPA calendar year, so join now to take advantage of great speakers for the next 13 months!
Monday, August 24 at 7:15 pm
Title: Shift Happens: Cognitive development, flexibility and remediation in eating disorders
Presenter: Kathleen Kara Fitzpatrick, Ph.D.
Description: CRT stands for cognitive remediation therapy (sometimes also called cognitive rehabilitation therapy). This type of treatment has been widely used in other disorders (most notably schizophrenia and traumatic brain injury). The focus of CRT is on creating different brain connections and learning to change the process of thinking. In our treatment, we focus on two main areas: set-shifting and central coherence.
Set-shifting refers to the ability to move readily between two (or more) different ideas, concepts or behaviors. You do this when you multi-task, but you also do this when you create habits. When you break a habitual behavior it can be a real challenge and the brain uses the same processes to create new connections around simple tasks (like changing the ringer on our cell phones) as we do to more complex behaviors (such as changing our minds about eating feared foods). Set-shifting is a skill we use every day, so we expect changes in certain areas to be helpful to us in every area.
Central coherence refers to the ability to move between details and the big picture. Most of us do this constantly, but we all show a preference for one or the other. People with AN seem to have a greater focus on details at the expense of the big picture and we engage in activities designed to help us learn how to better balance the global and detail perspective.
We hope that CRT helps in several ways. We know that people who undergo CRT improve in set-shifting and central coherence from other studies we have completed. And we know that the presence of more obsessive/compulsive symptoms typically mean greater challenges in these domains. We hope that the addition of CRT to FBT will reduce the amount of time it takes to help participants respond to treatment by focusing specifically on cognitive processes. We do not focus on content of thoughts – so we do not directly approach eating disorders – which can help facilitate our relationship with participants. Finally we also know that the adolescent brain is in the process of developing these skills and helping secure skill development provides a great foundation for all-important brain maturation.
Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 1000, Los Angeles) – free parking in the lot (enter on Highland)
Bio: Dr. Kathleen Kara Fitzpatrick is a Psychologist in the Stanford Dept of Psychiatry and Behavioral Sciences and Pediatrics. She specializes in neuropsychological assessment of eating disorders and evaluation of treatments for children and adolescents. Her current research interests focus on the development of Cognitive Remediation Therapy (CRT), which utilizes neuropsychological components to address cognitive and behavioral difficulties associated with eating disorders. In addition to working as a therapist on research treatment studies, she also provides supervision to therapists on different treatment modalities. As a therapist on the DSM-5 field trials, she conducted assessments to support changes in diagnostic criteria, with an emphasis on the new diagnosis of Avoidant Restrictive Food Intake Disorder.
RSVP to Dr. Lauren Muhlheim at email@example.com
SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org
Thursday, September 17 at 7:15 pm
Title: Full Metal Apron: Fighting Eating Disorders from the Kitchen Table
Description: Just when she thought it was safe to leave the kitchen, after feeding her family a home-cooked dinner nightly for 25 years, the youngest of JD Ouellette’s four children developed anorexia at the age of 17. Thankfully her daughter was diagnosed quickly and excellent treatment at UCSD was readily available. Three plus years after her daughter began treatment she is once again happy, healthy and free (for now) from her eating disorder and thriving in college and life. This talk will cover her family’s journey and the lessons she’s learned in her work as a parent mentor for UCSD as to how clinicians can help parents help their child recover.
Location: The office of Dr. Lauren Muhlheim (4929 Wilshire Boulevard, Suite 1000, Los Angeles) – free parking in the lot (enter on Highland)
Bio: JD is a member of the UCSD Eating Disorders Center’s Parent Advisory Committee, a parent mentor for UCSD, an active member of Eating Disorder Parent Support, a co-ed online support community, and co-administrates International Eating Disorder Action. She is an avid consumer of ED literature and attends ED conferences while holding down her day job as a school administrator. She has a passion for using social media to allow parents’ and other advocates’ voices be heard as advocates and activists in the ED world.
RSVP to Dr. Lauren Muhlheim at firstname.lastname@example.org
SIG meetings are open to all LACPA members. Nonmembers wishing to attend may join LACPA by visiting our website www.lapsych.org
I recently began volunteering at the Best Friends Neonatal Kitten Nursery. Best Friends Los Angeles opened its neonatal kitten nursery in February 2013. The nursery is staffed with a dedicated coordinator and supported by volunteers who sign up for two hour feeding shifts 24 hours a day to help the kittens grow and thrive.
If you were an abandoned kitten in the Los Angeles area, or even a kitten with a mother, you’d be lucky to make your way to the Best Friends Neonatal Kitten Nursery.
The most vulnerable animals in the Los Angeles shelters are newborn kittens, often abandoned at birth, or turned into shelters from accidental litters. Because the kittens cannot feed themselves, they will die without someone to bottle feed them.
In the mommy and me section of the nursery, mothers nurse their kittens. In the other sections, kittens are bottle-fed, tube-fed, or syringe-fed until they are able to eat gruel on their own. Kittens are weighed before and after each feeding. If their weights are not steadily going up, the interventions increase. They are very fragile at this age.
The other night, the nursery coordinator, Nicole, was tube-feeding some kittens who were ill. As she explained, they were feeling too sick to eat on their own. Although acknowledging that her tube feeding was making them angry, Nicole was resolute. No kitten would starve to death on her watch. Of course, I connected this back to my families working to re-feed their children with anorexia.
In the neonatal nursery, we don’t spend time thinking about why the kitten is not nursing or eating in the expected fashion. If they are sick, they are treated for that, but in the meantime, every kitten is fed around the clock and those who don’t have mothers are bottle fed, those who won’t nurse from their mothers (often when they are too congested) are tube-fed, and those who won’t eat gruel independently are syringe-fed.
How does this relate to parents doing Family Based Treatment (FBT) for Eating Disorders with children who have Anorexia?
Of course, parents do not literally force food down human children’s throats, but they do set up contingencies to require eating even if the child doesn’t feel well and even if they rail and resist and are angry about it.
This is the heart of FBT Phase 1. When children are not able to eat on their own (due to an eating disorder) parents are instructed to nourish their starving child back to health. Parents need to step in and help their children make steady weight gains until they are able to eat on their own. Parents need to be resolute and not worry about their children being angry at them. They also should not spend time exploring why their child is not eating.
For further information on parental direction over eating in FBT, check out this prior blog post.
Binge eating disorder (BED) has been making headlines with the recent announcement that the FDA has approved lisdexamfetamine dimesylate (Vyvanse) for the treatment of BED.
So, what is BED, how is it treated, and what does this new treatment option mean for persons with BED?
What is Binge Eating Disorder
BED is a condition in which a person engages in recurrent episodes of binge eating at least once a week for three months1. Binge eating episodes typically involve eating rapidly until uncomfortably full, and eating when one is not necessarily hungry. Some individuals with BED report feeling unable to stop the episode, and describe themselves as being out of control during a binge. Binge eaters often binge alone and make efforts to hide their behavior from friends, partners, or family members. Episodes of binge eating often end in feelings of guilt, shame, and depressed mood. Unlike other eating disorders, such as bulimia nervosa, people with BED do not vomit or use other methods of compensation (such as excessive exercise or fasting) to shed calories or lose weight after a binge. It should be clear that this is a very different experience than, say, overeating on Thanksgiving, having a second piece of birthday cake, or eating foods that are outside of your normal pattern while on vacation.
Until 2013, BED was not a diagnosable eating disorder. It was instead grouped in with other unspecified eating disorders that didn’t quite meet criteria to be formally diagnosed. After much research, the most recent iteration of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), has included BED as a specific eating disorder distinct from other diagnoses.
Despite only recently being formally acknowledged, BED is the most commonly occurring eating disorder. Prevalence estimates vary, ranging from 1.6-3.5% of women, 0.8-2% of men, and 1.6% of adolescents.1, 2, 3 BED occurs as commonly among women from racial or ethnic minority groups as for white women, 1 and is often seen in people with severe obesity.1, 4 Up to 30% of people seeking bariatric surgery or other interventions for weight loss are suffering from BED5. While it is more common for women to meet all of the criteria for BED, men tend to engage in binge eating as frequently as women2. Like all eating disorders, the causes of BED are complex. There is evidence for genetic, biological, and environmental risk factors. BED is associated with significant chronic health problems. It is also common for individuals with BED to struggle with other mental health disorders at the same time, including depression, anxiety, and substance use disorders.
The good news is that there are established treatments that work for BED. Unfortunately, effective psychological interventions for eating disorders don’t get as much press as pharmaceuticals. Nevertheless, those suffering from BED should be aware of what is available.
Treatment for Binge Eating Disorder
Evidence-based psychological treatments are first-line considerations for the treatment of BED. A psychologist or other mental health professional qualified to treat eating disorders usually conducts psychological treatment for BED on an outpatient basis. Cognitive behavioral therapy (CBT) is the most well studied and established treatment for BED with demonstrated effectiveness.6 The treatment involves reducing episodes of binge eating using tools such as establishing regular eating patterns and self-monitoring of food intake and patterns of eating. CBT also addresses concerns about shape and weight, and examines and challenges patterns of thinking that may be keeping a person stuck in a pattern of binge eating. CBT for BED involves discussion and planning of how to maintain progress, and how to recognize and respond to relapse. Studies have demonstrated improvements lasting up to 12 months post-treatment with CBT.7 Interpersonal therapy (IPT) has also been proven effective for BED with strong research support.8 IPT involves more of a focus on interpersonal (relationship) difficulties with an understanding of how these problems may have precipitated BED, or how they might be keeping the BED going. Finally, there is evidence that dialectical behavior therapy (DBT), which focuses on mindfulness, emotion regulation, and distress tolerance, is effective at treating BED.9
Pharmacological Treatments for Binge Eating Disorder
In addition to psychological treatments, antidepressants and anticonvulsants have proven helpful at reducing the frequency of binge eating in patients with BED.6 The newest and only medication specifically approved by the FDA for BED is Vyvanse, a central nervous system stimulant that has been approved to treat ADHD in children and adults since 2007. The approval for BED came after clinical trials demonstrated that the average number of binge eating days per week among sufferers were decreased in those who took Vyvanse, compared to those who took a placebo.10 Sounds promising…but there are other considerations to keep in mind…side effects, long-term use, and the question of whether a medication can address the complex nature of a serious eating disorder such as BED.
The potential side effects of Vyvanse include decreased appetite, dry mouth, increased heart rate or blood pressure, difficulty sleeping, anxiety, gastrointestinal problems, feeling jittery, and even sudden death among people with heart problems. The drug is also particularly risky for individuals with a history of seizures or mania. Vyvanse may cause psychotic or manic symptoms in people with no history of mental illness, and has a high potential for abuse, dependence, tolerance, and overdose.
Vyvanse appears to decrease symptoms over a short period of time (about three months) while taking the medication. However, it is unlikely that the medication will result in long-term changes in complex binge eating behavior once the drug is stopped, meaning that one might expect to take Vyvanse for the rest of their lives in order to keep BED at bay. This is problematic considering the chronic nature of BED, 2 and the fact that the negative emotion, distress, shame, and weight or shape concerns that are often related to BED would almost certainly remain unaddressed.
While there are no identified side effects to engaging in psychological treatment of BED, these treatments do take time (often around 20 weeks), and not every person will respond to an intervention the same way. It may take some trial and error to find the right therapist or treatment. However, psychological treatments are more equipped than medication alone to address the binge eating behavior itself, and the different ways binge eating relates to other areas of a person’s life and functioning. Rather than simply masking and reducing symptoms in the short term with a medication, completing a course of evidence-based therapy can provide the insight and tools needed for managing the patterns of disordered eating that are characteristic of BED for life. Many people with BED may benefit from trying a psychological approach before initiating treatment with a serious medication like Vyvanse.
Implications for Patients
All of these factors should be carefully considered when making a decision about treatment for BED. With all eating disorders including BED, it is important to get help sooner rather than later. For many people, turning to their primary care doctor is the first step. Patients should keep in mind that these conversations can be sensitive and difficult, and many providers may not be familiar with BED. Other providers may be familiar with the recent approval of a new drug, and will be eager to explore prescription medication options for treatment.
If you aren’t getting anywhere with your doctor, it is always appropriate to ask for a referral to a medical provider who is more familiar with eating disorders. Your doctor may also be able to provide you with a referral to a mental health provider, such as a psychologist, who can provide one of the therapies discussed above, and to a nutritionist or dietician who specializes in eating disorders for even more comprehensive support. Remember that it is important to seek help from professionals qualified to treat eating disorders, and treatment decisions should be tailored to the unique needs of each person.
1. American Psychiatric Association. (2013). The Diagnostic and Statistical Manual of Mental Disorders: DSM 5. bookpointUS.
2. Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological psychiatry, 61(3), 348-358.
3. Swanson, S. A., Crow, S. J., Le Grange, D., Swendsen, J., & Merikangas, K. R. (2011). Prevalence and correlates of eating disorders in adolescents: Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7), 714-723.
4. Marcus, M. D., & Levine, M. D. (2005). Obese patients with binge-eating disorder. In The management of eating disorders and obesity (pp. 143-160). Humana Press.
5. Kalarchian, M. A., Marcus, M. D., Levine, M. D., Courcoulas, A. P., Pilkonis, P. A., Ringham, R. M., … & Rofey, D. L. (2007). Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. The American journal of psychiatry, 164(2), 328-334.
6. Brownley, K. A., Berkman, N. D., Sedway, J. A., Lohr, K. N., & Bulik, C. M. (2007). Binge eating disorder treatment: a systematic review of randomized controlled trials. International Journal of Eating Disorders, 40(4), 337-348.
7. Wilson, G. T., Grilo, C. M., & Vitousek, K. M. (2007). Psychological treatment of eating disorders. American Psychologist, 62(3), 199.
8. Wilfley, D. E., Welch, R. R., Stein, R. I., Spurrell, E. B., Cohen, L. R., Saelens, B. E., … & Matt, G. E. (2002). A randomized comparison of group cognitive-behavioral therapy and group interpersonal psychotherapy for the treatment of overweight individuals with binge-eating disorder. Archives of general psychiatry, 59(8), 713-721.
9. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of consulting and clinical psychology, 69(6), 1061.
10. McElroy S. L., Hudson, J. I., Mitchell, J. E., et al. (2014) Efficacy and Safety of Lisdexamfetamine for Treatment of Adults With Moderate to Severe Binge-Eating Disorder: A Randomized Clinical Trial. JAMA Psychiatry.
Elisha Carcieri, Ph.D., is a licensed clinical psychologist (PSY #26716) practicing in the Los Angeles area. Dr. Carcieri earned her bachelors degree in psychology from The University of New Mexico and completed her doctoral degree in clinical psychology at Saint Louis University. During her graduate training, she conducted research focused on eating disorders and obesity, and was trained in using cognitive behavioral therapy (CBT) for eating disorders and other mental health disorders such as anxiety and depression. Dr. Carcieri completed her postdoctoral fellowship at the Long Beach VA Medical Center, where she worked with Veterans coping with mental illness, disability, significant acute or chronic health concerns, and chronic pain. In addition to cognitive behavioral strategies, she also incorporates alternative evidence-based approaches such as mindfulness, and acceptance and commitment-based strategies, depending on the needs of each client. Dr. Carcieri has experience working with culturally diverse clients representing various aspects of diversity including race/ethnicity, gender, age, disability, and size, and welcomes new clients from all backgrounds. She is a member of the American Psychological Association (APA), the Academy for Eating Disorders (AED), and the Los Angeles County Psychological Association (LACPA).
Parents charged with helping their children to recover in Family-Based Treatment often wonder 1) how to actually get their children to eat and 2) whether they will harm their children or the parent-child relationship by requiring them to eat. A recent study addressed these concerns by looking at the family meal.
Hannah J. White BSc (Hons), Emma Haycraft PhD,*, Sloane Madden MD, Paul Rhodes PhD, Jane Miskovic-Wheatley DCP/MSc, Andrew Wallis MFAMTher, Michael Kohn MD and Caroline Meyer PhD (Article first published online: 26 JUN 2014)
The above study in the International Journal of Eating Disorders looked at the family meal in Family-Based Treatment (FBT), the best-researched outpatient treatment for adolescent anorexia. In FBT, the family plays a central role in treatment. Parents take responsibility for weight restoration and interruption of eating disorder behaviors, and family meals are an essential part of this process. Typically the second session of Family-Based Treatment is a family meal in which the family brings a picnic meal to the therapist’s office. The goal of the session is for the therapist to empower the parents to get their child with anorexia to eat one bite more than the child was prepared to eat.
The strategies used during mealtimes by parents of adolescents with anorexia have not been previously documented. Some believe that the eating habits of these adolescents have regressed and that the adolescents should be viewed as younger children who need more feeding assistance from their parents. Thus, parental strategies used to encourage eating would be similar to the strategies used by parents of younger children with and without feeding problems, which have been studied: these parents have been noted to use both encouragement and pressure to eat. Little is known about the response of adolescents with anorexia to their parents’ attempts to get them to eat.
The purpose of this study was to examine the strategies used by parents and the results. The study included 21 families with children between the ages of 12 and 18 who were undergoing FBT for adolescent anorexia.
The main aims of the study were:
1) to identify mealtime strategies used by parents during the family meal session of FBT.
2) to explore the relationships between these strategies and parental ‘success’ in encouraging eating.
3) to explore the relationships between these strategies and their results with the emotional tone of the mealtime.
While this research was conducted in an artificial setting – a therapist’s office and in the presence of the therapist – the findings should be applicable to family meals occurring in the home.
Specifically, the researchers found:
1) parents used a variety of strategies to prompt the child to eat: direct eating prompts (e.g., “You’ve got to eat all your eggs” or “Pick it up and eat it”), non-direct eating prompts (e.g. “Keep going” or “Why don’t you eat some more pasta?”), physical prompts (e.g., pushing a plate of food towards the adolescent), autonomous comments (e.g., “Do you want another one?” or “Which one do you want?”) and information provision (e.g., “Your body needs the calcium” or “This will make your bones strong”).
2) direct, non-direct, and physical prompts were more successful in getting adolescents to eat than providing information about the food or offering food-related choices to the adolescent.
3) in general, the more the parents prompted the child to eat and the more successful they were, the more negative the adolescents became. It makes sense that attempts to encourage eating, which contradict the anorexic tendencies, would cause psychological distress and a more negative emotional tone.
The authors conclude “It is interesting that a behavioral focus on eating (i.e., verbal and physical prompting) was associated with parental success as opposed to other strategies such as offering choices to the adolescent or consequences. This indicates that parents implementing a direct focus on food may be central to eating behavior and supports the emphasis on behavioral change rather than insight which is central to FBT.”
Keeping in mind that this is only one small study, the results are consistent with my observations of family meals in my practice and reports from parents refeeding their adolescents:
parents need to directly prompt or pressure their child with anorexia to eat.
offering choices and providing information is generally less effective in getting children with anorexia to eat.
the more the parents pressure the child and the more the child eats, the more negative and upset the child becomes.
This study highlights the paradox parents face in implementing FBT. When a child is in distress, the parental instinct is to try to soothe them. Intentionally upsetting the child runs counter to a parent’s nature. However, for children with anorexia, food is medicine. The best measure of the parent’s success in FBT is the amount of food consumed. Parents should expect that their child will have a negative reaction to both pressure to eat and the eating itself. This negativity is not a sign of failure, but a reaction to a treatment that is working.
While these interactions often lead to more short-term conflict and distress, parents must persist and weather the storm in order to support their child’s recovery. Over time, this persistence will challenge the anorexia and encourage change and recovery.
I remain committed to the practice of and dissemination of evidence-based treatments. To that end, I am excited to announce that I have added a registered psychological assistant to my practice in Los Angeles:
Liliana Almeida, M.A, Clinical Psychology Ph.D. Student, PSB-94020579 is no longer with the practice, but we do have a new therapist in training who provides low-cost therapy to patients with eating disorders in Spanish, English, and Portuguese. Learn more about Eliane Spagnoletto, ACSW.
Liliana Almeida, M.A., is a fourth year Clinical Psychology Ph.D. student at the California School of Professional Psychology at Alliant International University in Los Angeles. She received her M.A. from The New School and her B.A. from Rutgers University. During the last 7 years she has researched eating disorders and obesity. Her clinical experience includes working with diverse clients in a community mental health center providing cognitive-behavioral and psychodynamic psychotherapy in English and Spanish.
Liliana will be working under my supervision and is available to work with adult and adolescent clients with eating disorders, anxiety, and depression. She will provide services in English, Spanish, and Portuguese and will be able to provide some low-cost therapy to those in need.
Eu sou uma assistente de psicologia (PBS-94020579) para Lauren Muhlheim, Psy.D., psicóloga clínica especializada no tratamento cognitivo-comportamental de perturbações alimentares. Como assistente de psicologia, eu forneço psicoterapia cognitivo-compartamental em Português sob a licença da Dra. Muhlheim (PSY 15045) para adolescentes e adultos que sofrem com depressão, ansiedade e pertubações de o comportamento alimentar.
Soy una asistente de psicología (PBS-94020579) para Lauren Muhlheim, Psy.D., una psicóloga clínica especializada en el tratamiento cognitivo-conductal de los trastornos alimentarios. Como asistente de psicología yo proveo terapia cognitivo-conductal en Español bajo la supervision y licencia de la Dra. Muhlheim (PSY 15045) para adolescentes y adultos que sufren de la depresión, ansiedad y de los trastornos de la conducta alimentaria.
ICED 2014 in New York provided a wonderful opportunity to connect with colleagues from around the world who share a commitment to providing treatment to those suffering from eating disorders. Among the highlights for me were the well-attended, first-ever tweetUP and my official appointment as Board Director for Outreach of the Academy for Eating Disorders.
Among the workshops, I was very excited to attend A Comprehensive and Measured Critique and Discussion of Maudsley and Family Based Therapy: The Civilizing Influence of Rigorous and Impartial Debate. In this workshop, UCLA Eating Disorders Program director Dr. Michael Strober, one of the more vocal critics of Maudsley Family Based Treatment (also known as FBT), went head to head with Dr. Daniel LeGrange, director of the University of Chicago’s Eating Disorder Program and one of the developers of FBT. As one of a handful of therapists in Los Angeles certified in FBT, I am highly aware of Dr. Strober’s criticisms of the treatment.
Dr. Strober introduced the packed-room debate by saying, “there will be no flowing of blood at the FBT debate.” Dr. LeGrange presented first and cited the empirical evidence for FBT, admitting “it is no panacea” as there are only 7 published controlled trials. He reported the “most compelling” study of FBT showed that 45% of those who received FBT fully remitted, versus only 20% of those who received Adolescent Focused Therapy. He noted that FBT is particularly helpful in rapid weight restoration and in a reduction of the need for hospitalization.
Dr. Strober countered by stating, “there is [only] a sprinkling of evidence in support of FBT.” He argued that the evidence for FBT was actually weak, with only 3 published comparative studies. He pointed out there was no statistically significant end of treatment outcome for FBT. Strober concluded that there is a lack of evidence to suggest FBT is the treatment of choice for all patients. He cautioned that the “glossy language” used by FBT’s proponents needs nuance: “The public discussion is the problem; well-trained clinicians have been accused of acting unethically by not recommending FBT.” Strober stated that his questions regarding FBT’s efficacy have led to hostile, finger-pointing treatment from others. “It’s not that FBT lacks value but that [any critique or questioning of it is dismissed as unethical & unfounded]”. He conceded that FBT should not be dismissed: “I recommend it at times when the rationale is sound.” He joked, “I have been asked why I hate families; as far as I can tell the only family I hate is mine; I quite fancy the others.”
In his rebuttal, Le Grange agreed with Dr. Strober, “It concerns me too that FBT is being touted as the be-all-end-all.” However, he noted that it was still the approach that currently has the best evidence supporting its overall efficacy. LeGrange acknowledged “we are clutching at straws” to find effective treatments for eating disorders. “I agree we need to move forward, with much more rigor, to continue to evaluate the efficacy not just of FBT but also other ED treatments.”
In summary, there was more agreement than disagreement. Both experts acknowledged that while FBT has value, the research is still young. The audience encouraged them to write a paper together on the strengths and limitations of FBT, with the objective of depolarizing the eating disorder community.
For my part, in the outpatient setting in which I work, I will continue to offer FBT to adolescents with eating disorders and their families when the illness duration is under three years, when the adolescent is medically stable and cleared for outpatient treatment, and when the home environment is stable and the parents are committed to FBT. If early weight gain is not achieved, I always recommend a higher level of care.