Anxiety Eating Disorders Psychotherapy

EMDR for Eating Disorders

EMDR and Eating Disorders [close up of an eye]
Photo by Amanda Dalbjörn on Unsplash

By Runjhun Pandit, LPCC

EMDR….Sounds scary.

EMDR therapy, these acronyms make it sound like a scary treatment intervention. And oftentimes, when I mention this to my clients, they feel scared or confused. They do have questions about how it works and how it is different from hypnosis.

Eye Movement Desensitization and Reprocessing (EMDR) is a treatment specifically created to help people deal with a traumatic situation. It was initially developed for veterans who suffered flashbacks and nightmares upon return from war and were trying to readjust back to life with their families. Soldiers experienced reenactment of the wars in their dreams, emotional outbursts leading to frequent conflicts with their families, inability to maintain steady relationships, and dissociation from reality. EMDR hence was developed by Francine Shapiro, Ph.D. with the assumption that eye movements could assist in desensitizing to a traumatic situation. 

The limbic system in our brain is responsible for our behavioral and emotional responses while the brainstem and cortex are the areas that help in relaying the message from the spinal cord to the brain and store the verbal story of the events in our daily lives. When a person experiences a traumatic situation–like an accident or exposure to prolonged emotional distress like abuse or neglect– the usual coping mechanism that would help the person effectively “process” the situation, goes into overdrive. And the limbic system isolates this memory and stores it in the form of an emotional and physical sensation. Due to this isolation, the cerebral cortex doesn’t remember the “story” but the limbic system sends out an emotional response when some events in the present trigger some areas of the traumatic event. Hence, even if the memory is forgotten, the emotions attached to the memory– like pain, anxiety, or body sensations– continue to trigger the person in the present. This prevents a person from experiencing new situations or from living in the moment since oftentimes some parts of the present emotionally burden the limbic system. 

During EMDR sessions, the therapist creates a treatment plan and simulates eye movements similar to the ones that occur during REM sleep by asking the client to follow their fingers. Our brain has the natural capacity to heal itself. During the session, the therapist might also use a light bar to help you track the light across the visual field. These movements last for a minute and the therapist will ask you to report any experience–such as a change in emotions,, memories, or thoughts–after each set of eye movements. By repeating this process, the traumatic memory eventually loses its emotional charge and gets stored in the mind instead as a neutral memory. Frequently, people also have smaller memories associated with the actual traumatic memory which also may get resolved along the way. It has been noted that the “healing” of these smaller memories also creates a noticeable change in a person’s life. 

Although EMDR was developed for Post Traumatic Stress Disorder (PTSD), growing evidence shows that it may also be helpful for the resolution of panic attacks, anxiety, depression, eating disorders, and negative body image. EMDR helps clients process the traumatic memory and assimilate it in a healthier way without an emotional charge. Studies have shown that EMDR can be used in conjunction with Family-Based Treatment (FBT) or Cognitive-Behavioral Treatment (CBT) since these treatments focus on the here and now of the eating behavior while EMDR focuses on the past experiences around body image or food that maintain the disordered eating behaviors. Research has shown that EMDR generates a connection between body, emotions, and cognitions by allowing the elaboration of traumatic events and simultaneously resolving the emotional blocks attached to the traumatic memories. 

A complete EMDR treatment helps the person to “walk through” previously considered traumatic events with greater emotional and impulse control which eventually leads to an increase in feelings of self-worth and self-esteem. 

Runjhun Pandit, LPCC is available to see adolescents for EMDR via telehealth. EMDR can be helpful for food-related traumas and other traumas that might perpetuate eating disorder symptoms such as bullying, body shame, and other invalidating experiences.  To make an appointment with Runjhun Pandit, complete this form


Bloomgarden A, Calogero RM. A randomized experimental test of the efficacy of EMDR treatment on negative body image in eating disorder inpatients. Eating Disorders: The Journal of Treatment and Prevention. 2008; 16(5): 418–427.

Maria Zaccagnino, Cristina Civilotti, Martina Cussino, Chiara Callerame and Isabel Fernandez (February 1st 2017). EMDR in Anorexia Nervosa: From a Theoretical Framework to the Treatment Guidelines, Eating Disorders – A Paradigm of the Biopsychosocial Model of Illness, Ignacio Jauregui-Lobera, IntechOpen, DOI: 10.5772/65695. Available from:

Verardo A, Zaccagnino M, Lauretti G. Clinical applications in the context of attachment: the role of EMDR. Clinical applications in the context of attachment: the role of EMDR. Infanzia e Adolescenza. 2014; 13: 172–184

Eating Disorders Psychotherapy

Do I Need to Quit X to Stay in Recovery?

Image by Zorro4 from Pixabay

By Carolyn Hersh, LCSW, Staff Therapist

A difficult concept in recovery is knowing when to let go of an activity or even a job that could potentially re-ignite the eating disorder. As a therapist I find myself guiding my clients towards the realization that the sport or career path they had loved so much might be the very thing that holds them back and sets them back up for relapse. It isn’t always an easy decision.

Letting go of something that may have predated the eating disorder can lead to questions as to why it cannot remain in someone’s life in recovery. Many clients in the early stages of eating disorder treatment have to face the fact that they have to stop their sports if they are trying to regain weight or are working on eliminating behaviors that could leave the body physically weak. It is no surprise that once stabilization begins there is an urge to return to previously enjoyed activities. However, returning to these activities could potentially hinder full recovery.

Sports like gymnastics, running, figure skating, wrestling, and dancing are incredibly wonderful. As a figure skater myself, I can attest there is no greater feeling than gliding over the ice. But these same sports, especially at the elite level, can be incredibly demanding on the body. Behaviors required for full recovery can go against what a coach may be preaching to athletes to be in top physical form. What is expected of top athletes could look like disordered eating and poor body mentality from an outside perspective. The eating disorder itself may take what is used to condition a top athlete and manipulate it for its own gain.

It can be difficult to find the balance between a recovered mindset and meeting the demands of a sport or career. With some of my clients in the entertainment industry, there are pressures to look a certain way and fit a mold that their bodies may not be meant to fit. It can be difficult to navigate knowing they need to eat a certain amount of times a day and then have an agent say, “Lose five pounds for this role.”

The hardest decision is when there is a realization that staying in either the sport or career is just too detrimental to your health. It is certainly not easy to walk away from something you’ve put work into. And that can also be said about your recovery. Are you willing to give up a healthy body and mind for a potential chance at a gold medal or lucrative career even if it means killing yourself along the way? I’ve worked with a client who was a dancer who recognized as she was going through treatment that going back into a dance studio would be too triggering. She knew that staring at herself in a mirror and comparing herself to her classmates would lead to restricting her meals. It wasn’t an easy decision to walk away, but she knew there was no way she was in a place to be able to dance without being triggered.

In some circumstances, you may not have to completely quit your previous passion.  You might be able to approach the activity differently. You may not be able to return to a sport as an elite athlete, but you could still engage in the activity at a more recreational level. I’ve seen some of my clients shift from being an athlete to being a coach. Actors going from television and movies to doing local theater.  Sometimes you can still do what you love but it just needs to be re-configured to fit into your recovery lifestyle. For many, it can be comforting to know they can still act or model or run, but just do it less intensively.

You may also have the option of challenging what a sport or career emphasizes as far as body image and diet pressures. There are many models and actors who are embracing bigger bodies and not letting the pressures to lose weight define them. With this option, there is a risk of rejection along the way as we do still live in a culture that overvalues thinness. With that being said, this may be a safe option primarily for those who feel stable in recovery and are able to actively use coping skills to fight urges. If your recovery has reached a place of advocacy this definitely could be a path to take.

Leaving a passion behind or re-defining how it fits into your life can be a huge change. You may feel sad or mad. That’s okay. Ultimately, the decision you make will be the one that supports you in your recovery. If staying in the activity is going to trigger calorie counting, weekly weigh-ins or criticism for not looking a certain way, is it worth it? If you know where the eating disorder thrives then why play with fire? Ultimately, the decision will be based on what will make you healthy and happy and not allow you to compromise with the eating disorder.

Eating Disorders Grief Psychotherapy

Recovery When Grieving by Carolyn Hersh, LCSW

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 

Eating Disorders Psychotherapy

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

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!


Sleep: Monitoring and treatment of insomnia without drugs

By Elisha Carcieri, Ph.D.

“A ruffled mind makes a restless pillow.” Charlotte Bronte

In our self-obsessed culture, monitoring and tracking heartbeat, steps, exercise, food intake, and sleep is commonplace. My sister has recently been tracking her sleep using an app on her smartphone, and she encouraged me to do it too. My first response was, “Why? I know I’m sleep deprived. I don’t need an app to tell me that.” I was still nursing my baby once a night at the time and I was pretty positive this was negatively impacting my sleep and my ability to function in general. Skeptical, I downloaded the app and started it each night before bed for about a week. The application’s primary measure of sleep quality is called ‘sleep efficiency,’ which is the amount of time you are asleep divided by the amount of time you are in bed, and is represented as a percentage. This is the same measure of progress I use with clients in cognitive-behavioral therapy for insomnia (CBT-I). Typically, sleep efficiency of 85% or higher is considered “normal,” “healthy,” “good” sleep. For example, if you are in bed for 8 hours, asleep for 7.5 of those hours, with 20 minutes to fall asleep and two episodes of waking for 5 minutes each, your sleep efficiency is 94%.

The app uses the microphone on your smart phone to measure whether you are awake or asleep based on movement. Years ago, when I worked as a student clinician at a sleep and pulmonary disorder clinic, we used actigraphy watches which then had to be downloaded, interpreted by hand, and then compared with self-report data. Amazing what smart phones can do!

I was somewhat surprised at what the app told me. Many of the nights I was sure my sleep was poor, “I didn’t sleep a wink last night,” the app indicated that, while I was awake for some of the time (feeding my baby), I was out like a light during the time I was in bed. A user-friendly graph depicted the movement associated with my sleep, and decent average sleep efficiency. I learned from a week of monitoring that I should prioritize getting to bed earlier, because when I am in bed, I’m sleeping. While I am not suffering from insomnia, the little experiment reminded me of the benefits of brief self-monitoring, and inspired me to share some information about insomnia and its treatment.

What is insomnia, anyway?

Most people have bouts of insomnia at some point in their lives, usually in response to a stressful event. These short episodes of sleeplessness usually resolve and don’t require treatment. Chronic insomnia last for months or years and can be characterized by:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality sleep

Consequences of insomnia include fatigue, sleepiness, difficulty with thinking (attention, concentration, memory), irritability, headaches, poor work performance, and persistent worry about sleep.

It is thought that insomnia develops as a result of three factors: predisposing factors, precipitating factors, and perpetuating factors. Predisposing factors are risk factors for developing insomnia, such as a highly sensitive biological sleep system or a tendency toward high arousal. Precipitating events are usually stressful events that result in an initial loss of sleep; for example, loss of a loved one, a stressful move, a new job, etc. Most people recover from this initial sleep loss once the stressor resolves. But the perpetuating factors play one of the biggest roles in the development and maintenance of insomnia. Some people become highly focused on their sleep difficulty, which results in heightened anxiety, maladaptive behavioral responses (going to bed early, staying in bed late, avoiding evening activities for fear that it may interfere with sleep, developing sleep rituals, or “crutches”), and unhelpful thoughts, attitudes, and beliefs about the sleep problem. Some examples of these common dysfunctional beliefs are:

“I need 8 hours of sleep to feel refreshed and function well during the day.” 

“When I sleep poorly on one night, I know that it will disturb my sleep schedule for the whole week.”

“When I feel tired, have no energy, or just seem not to function well during the day, it is generally because I did not sleep well the night before.” 

“Medication is probably the only solution to sleeplessness.”

These beliefs tend to perpetuate insomnia by further increasing worry and arousal, focusing attention on negative consequences of lost sleep, and decreasing belief in your ability to control your sleep problem. These patterns of thinking, in addition to the well-intentioned but detrimental behavioral responses to sleep loss are the critical targets of CBT for insomnia.

How is insomnia treated with CBT?

Many people believe that medication is the only answer to chronic insomnia. However, CBT for insomnia (CBT-I) is safe, brief (usually 4-5 sessions), has lasting effects, and is well researched. CBT-I is composed of education about sleep, stimulus control strategies, sleep restriction, relaxation training, and “sleep hygiene.”

Stimulus control strategies address the issue of the bed and sleeping environment becoming associated with wakefulness, rather than sleep. In a nutshell, the recommendations go something like this:

  • Go to bed only when sleepy (not just fatigued or tired)
  • Use the bed and bedroom only for sleep (and sex)
  • If unable to sleep, get out of bed and return to bed only when sleepy
  • Wake up at the same time every day regardless of how much you slept
  • Do not nap

Simply put, implementing stimulus control strategies is not fun. Getting out of bed when not sleeping is annoying and takes work. Also, many people with insomnia have the unfounded belief that if they just stay in bed and “rest,” they will increase their likelihood of falling asleep and will at least get some R&R. In reality, more time spent in bed awake will only perpetuate the insomnia, and rest is not equal to sleep.

Occasionally, a strategy called sleep restriction is used in which the amount of time in bed is restricted to the amount of sleep a person typically needs to feel rested. This process can also be unpleasant as it results in an initial loss of additional sleep. However, after a few days, most people begin to see results.

Relaxation training can help to address the increased anxiety and arousal associated with insomnia and the process of sleep. Learning breathing and muscle relation techniques such as progressive muscle relaxation can be important targets for the management of insomnia. If bothersome thoughts and worries are a major component of insomnia (which is often the case for those who have difficulty falling asleep), taking time out of the day to focus on worries and write them down can be helpful.

Sleep hygiene recommendations are a beneficial add-on to the treatment of insomnia (but are not usually sufficient treatment) and are applicable to most “normal” sleepers. The following are some of the guidelines I’ve found to be the most powerful:

  • Wake up at the same time each day regardless of bedtime – This is part of the stimulus control instructions as well. Bedtime can be more difficult to keep consistent.
  • Avoid naps – Especially in the afternoon, naps reduce your sleep drive and may make it more difficult to get to sleep at bedtime.
  • Get regular, daily exercise – …but not right before bedtime (this can delay sleep onset).
  • Don’t watch the clock!!! – Checking the clock during a normal, middle-of the night waking can trigger many of the negative cognitions associated with insomnia and is likely to promote wakefulness.
  • Keep a quiet and comfortable sleeping space
  • Establish a pre-sleep routine and follow it nightly (e.g. wash your face, brush your teeth, change into pajamas, read for pleasure)
  • Avoid going to bed hungry
  • Avoid coffee, alcohol, and nicotine – especially in the afternoon and evening.

The use of electronic devices around and up to bedtime and in bed is a problem that is becoming more and more ubiquitous and is associated with poor sleep outcomes. Using a cell phone, tablet, computer, etc so close to bedtime can be problematic for a couple of reasons, listed below:

  • Blue light exposure – Smart phones and other devices emit light that has the potential to disrupt the sleep cycle and the brain’s “understanding” that it’s time for sleep.
  • Alertness/stimulation – Engaging with your device in the bedroom environment, especially in bed, serves to associate bed and the bedroom with alertness, rather than sleep.
  • Worry – Checking email right before bedtime or in the middle of the night can initiate worry and anxious thoughts about the following day, tasks that need to be done, etc.

Remember, if you do not have a sleep problem and “problematic” sleep hygiene-related behaviors are not affecting your sleep in a negative way, don’t worry about it! But these behaviors can be important aspects to consider for those who are suffering from a long-term sleep problem.

There are good self-help resources for insomnia both online and in book form. The Centre for Clinical Interventions (CCI) has some solid information sheets, and the book Quiet Your Mind and Get to Sleep is recommended. It can sometimes be difficult to find a CBT-I provider, but there is a directory of member providers on the Society of Behavioral Sleep Foundation website:


Carney, C., & Manber, R. (2009). Quiet Your Mind and Get to Sleep. New Harbinger Publications.

Morin CM; Vallières A; Ivers H. Dysfunctional Beliefs and Attitudes about Sleep (DBAS): Validation of a Brief Version (DBAS-16). SLEEP 2007;30(11):1547-1554.

Spielman AJ, Caruso L, Glovinsky P. A behavioral perspective on insomnia. Psych Clin N Am 1987; 10: 541±553.


Eating Disorders Psychotherapy

Raising the Bar: Competence in Outpatient Eating Disorder Treatment

Lauren and Alli with Charles Portney, MD (who enthusiastically gave us feedback) at ICED 2016.

When my friend and colleague, Alli Spotts-De Lazzer, M.A., MFT, LPCC, CEDS, asked me to join her in writing an article on competence for therapists treating eating disorders, I jumped at the opportunity.

Psychotherapists are ethically bound to treat within their scope of competence. Yet how does a psychotherapist determine if he or she is competent to treat eating disorders, the mental disorders with the highest mortality rates? Alli had searched for a guide or brief resource to help clinicians in training to better understand the basic knowledge recommended for treating eating disorders. To our surprise, few documents existed. Furthermore, we have both often heard that patients and families would like to feel better supported in knowing how to verify the credentials of outpatient eating disorder therapists. Many insurance companies do little vetting in choosing which therapists are listed on their panels as eating disorder treatment providers.

So we decided to create what we hoped would be a helpful document.

Alli and I each have extensive experience treating eating disorders in the outpatient setting. We come from different and complementary backgrounds. I received my original training in the 1990s in an evidence-based research lab under the direction of Terry Wilson, Ph.D, a developer of Cognitive Behavioral Therapy for eating disorders, and I have focused on evidence-based treatments ever since. Alli aligns with an eclectic approach informed by evidence-based concepts, personal experience with eating disorders and eating disorder trainings that range from Continuing Education Units to pre-licensed work at Monte Nido Treatment Center under the leadership of Carolyn Costin.

While we acknowledge that there are many possible paths to becoming a psychotherapist who treats eating disorders, we sought to answer questions including:

  • What set of competencies seem necessary for therapists to know in the outpatient setting?
  • What are many of the unique therapeutic needs of patients with eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder?
  • What basic knowledge and training might therapists pursue if they desire to treat eating disorders in the outpatient setting?

In addition to a mental health treatment focus, patients with eating disorders also commonly present with nutritional and medical issues that may need attention. While having well trained, collaborative team members covering medical and nutritional disciplines in a patient’s care is desirable, in a real-world outpatient setting, these team members may not always be available. Psychotherapists working in the outpatient setting who do not have well-established protocols, resources, or collaborators can be particularly vulnerable if/when issues of competence arise.

Eating disorders are psychological disorders that often come with physical, medical, or nutritional consequences and/or complications that call for acute or gradual attention. Psychotherapists, therefore, are recommended to have a basic working knowledge of eating disorder-specific domains extending beyond a psychotherapist’s traditional scope of practice and usual training. Furthermore, each major disorder – anorexia nervosa, bulimia nervosa, and binge eating disorder – can present unique treatment needs and levels of risk.

Our review of the literature incorporating both research and practice guidelines, in conjunction with our own clinical experience in treating eating disorders in the outpatient setting determined that the areas of suggested knowledge generally fell into 5 domains:

  • Assessment and Diagnosis
  • Medical Factors
  • Nutrition and Malnutrition
  • Treatment Strategies
  • Multidisciplinary Collaboration and Levels of Care

Our hope is that the paper will:

  • Help therapists treating eating disorders in the outpatient setting by providing accessible information and resources and assist in potentially improving the experiences of and outcomes for patients;
  • Serve as a useful guide for clinicians desiring to specialize in the treatment of eating disorders;
  • Assist patients and families in feeling more supported by knowledge when seeking treatment providers; and
  • Possibly help to influence insurance companies in the realm of eating disorders.

We are grateful to the following colleagues who gave valuable, substantial feedback on drafts of our paper: Jennifer Thomas, Ph.D.; Charles Portney, M.D.; Stacey Rosenfeld, Ph.D.; Laura Collins; Kristine Vazzano, Ph.D.; Nina Savelle Rocklin, Psy.D; and Elisha Carcieri, Ph.D. We received considerable research assistance from eating disorders informationist, Millie Plotkin. We also thank our additional valued colleagues who provided helpful comments.

After an extensive peer-review process, the paper, “Eating Disorders and Scope of Competence for Outpatient Psychotherapists,” was accepted by and published in the American Psychological Association Journal, Practice Innovations, 2016, Vol. 1, No. 2, 89–104.

Binge Eating Disorder body image Eating Disorders Los Angeles Psychotherapy

Male Eating Disorders










Despite being widely thought of as a disorder primarily affecting females, we know that people of all genders experience eating disorders. The experiences of males with eating disorders may be different so read on to learn more.

Prevalence rates

It is difficult to know exactly how many males are affected, partly because they have not been researched as much and partly because they are less likely to get diagnosed and treated.

Although it is widely quoted that only 10% of people with eating disorders are male, this is a likely underestimation. More likely, approximately 25% of individuals with anorexia nervosa and bulimia nervosa are male. Males make up even a larger percentage of the people with two more newly recognized diagnoses, Avoidant Restrictive Food Intake Disorder (ARFID) and Binge Eating Disorder. It is estimated that 40 percent of people with binge eating disorder are male. As many as 67 percent of children with ARFID may be male.


Eating disorders in males have been noted since 1689, when Richard Morton, an English physician, described 2 cases of “nervous consumption,” one in a male patient. Males later fell off the radar of eating disorders. Less than 1% of the papers on eating disorders focus on males.


Males have been largely excluded from the literature and research on eating disorders due to a variety of factors including stigma and biased assessment measures. Men may be less likely to endorse symptoms of what is commonly seen as a female illness and reluctant to ask for help. Because eating disorder awareness efforts typically target only girls, boys and men also may be less aware of eating disorders and less likely to recognize their problem as one. For these various reasons, males are likely underreported in prevalence statistics.

Additionally, since all of the available measures used to assess eating disorders were designed for females, they may not capture males with eating disorders. For example, the Eating Disorders Inventory has a question, ” I think my thighs are too large. ” This item is less likely to be endorsed by males because it does not reflect their body image concerns. A male-specific eating disorder assessment tool is the Eating Disorder Assessment for Males (EDAM). For example, a corresponding item on the EDAM might be something similar to, “I check my body several times a day for muscularity, ” which is more oriented toward males’ concerns.


One of the most striking differences between males and females with eating disorders is the difference in body image concerns. This seems to be a reflection of the difference between perceived ideal female and male bodies. While women are encouraged to be thin, males are encouraged to be muscular. There is research indicating that while the ideal body shape for females has gotten thinner over the years, corresponding research shows the ideal for men has gotten bulkier and more muscular.

Whether an eating disorder presents as a desire for thinness or muscularity appears to be related primarily to gender role identification; that is, feminine self-identification appears to be a risk factor for the development in men of thinness-oriented eating disorder psychopathology, while masculine self-identification is linked with the drive for muscularity and may contribute toward the development in men of muscularity-oriented body image concerns.

There is a question as to whether muscle dysmorphia is a type of body dysmorphia (itself a type of obsessive-compulsive and related disorders) or an eating disorder. Dr. Stuart Murray’s research supports that it is an eating disorder because it typically includes both compulsive exercise practices and disordered eating. Disordered eating practices are usually central to muscle dysmorphia, which is why it is not just body dysmorphia. As with female eating disorders, the compulsive exercise practices associated with muscularity-oriented eating disorders are often driven by appearance rather than health or performance.

Muscularity disordered eating may look quite different than the disordered eating more commonly seen in females. Girls and women with eating disorders usually restrict intake of high calorie food items. Males with eating disorders may increase their intake, especially of protein sources, and may also use appearance-enhancing substances such as supplements, steroids, growth hormone, and clenbuterol.

Other Differences Between Male and Female Eating Disorders

Exercise is more central to male presentations of bulimia nervosa than is purging or laxative use. Male eating disorders most typically involve two dimensions for male body image: leanness and muscularity. These may often be mutually exclusive. This can cause a cyclical nature to male eating disorders of bulking (weight gain) followed by cutting (weight loss). Males with bulimia may also not engage in typical binge eating, but may instead have “cheat meals.”

Males with eating disorders have a later age of onset, a greater likelihood of previous overweight status, greater psychiatric comorbidity, and a greater risk for suicidality. They are also less likely to seek treatment and when they do, it is common after a longer period of illness, which reduces the likelihood of a full recovery. Males suffer from many of the same medical issues as females with eating disorders but also may experience decreased testosterone and problems with sexual functioning.


Treatment for male patients with eating disorders must be gender-sensitive and address the stigma of being seen for what is commonly known as a female disorder. Clinicians should explore with male clients what it means for them to be male and how their body reflects that. Treatment with males often focuses more tightly on addressing exercise, which is often the first symptom to present and the last to remit.

Male Eating and Body Image Therapy Group

Learn more about EDTLA’s Eating and Body Image Therapy Group for Men ledy by Jonathan Dang, LMFT


My work in Shanghai with clients from all over the world

Eight years ago this month, I moved to Shanghai for a 2.5 year assignment.  I have been meaning to share my reflections.  Here they are:

I had been working at Los Angeles County Jail for nearly 10 years when my husband’s business plan for a site-based English Language Learning Children’s business in China got funded by the Walt Disney Company. I was by then more than a little “burned out” and ready for a change.

I know my jail co-workers questioned the legitimacy of my excuse for finally “getting out of jail.” “Really, you’re going to China?” they asked incredulously, as if I were just naming the furthest place I could think of from Los Angeles County Jail. I left my job in November 2007 and became wistful. I wondered if my kids would ever be able to remember having a working mother (they were 10, 8, and almost 6 when we left).

And so, in January 2008, my husband and I packed up our house, 3 kids and a dog, and said goodbye to our family and life in Los Angeles. We arrived in Shanghai during its coldest winter in 20 years.

Within 2 weeks of my arrival, I had coffee with a Dutch psychologist who lived in my compound and supervised the counseling program through the expatriate community center. Knowing of my expertise in eating disorders from my CV, she immediately handed me 2 cases. A friend encouraged me to apply for a job with the Singapore-based Parkway Health, which ran clinics throughout Shanghai staffed by Western-trained doctors, serving a predominantly expatriate clientele. Parkway Health promptly hired me, and within 4 months of my arrival in China I was working two jobs.

My clients were anyone who could speak English. This included clients from every continent with the exception of Antarctica (I never got to treat any penguins!). They ranged in age from children to adults in their 60s. The majority were on expatriate assignments or had children with foreign passports attending international schools. Some were Chinese who had lived abroad and were now living in China while their children attended international school. Others were American-born Chinese who had come to work in China and faced significant cultural issues. Other clients came from the UK, Germany, Brazil, Argentina, Sweden, Canada, Israel, India, South Africa, and Australia.

Map in my office in Shanghai with pins representing hometowns of patients.

I learned that clients around the world experience very similar problems. Due to my specialty, a significant portion of my clients was seeking treatment for eating disorders. But with a short supply of therapists to treat the large and diverse population of expats in Shanghai, I also saw clients with anxiety, mood disorders, and marital problems.

I found that the stress of being an expat away from one’s family and home, and the clash of living in a foreign culture, added overlays of additional stress to whatever other disorder or issues were already there. I also found that there were a certain number of individuals who had fled their location of origin (sometimes a series of locations) in an attempt to run away from a problem; unfortunately, in these circumstances the problems had merely followed them to China.

A Cognitive Behavior Therapy (CBT) approach provided benefits for clients of diverse ethnic backgrounds. I sought additional training in Emotionally-Focused Therapy for couples and Family-Based Treatment for adolescent eating disorders to enhance my skills.

One of the most exciting aspects of living and working in Shanghai was spearheading the establishment of the Shanghai International Mental Health Association (SIMHA), an organization for therapists serving the international community of Shanghai. Over time, I proactively cultivated relationships with anyone who had been a therapist. This aided me when I needed to consult or refer to another therapist. Unfortunately, although various international schools and organizations serving expatriates retained lists of expatriate therapists, whichever list I consulted of therapists practicing in Shanghai was outdated (and the turnover was relatively rapid). Thus, I reached out to the International Mental Health Practitioners of Japan and sought their advice on forming a similar organization in Shanghai. I then banded together the various and diverse therapists I had identified in Shanghai and together we formed a professional organization of mental health professionals (also from all around the world), adopted an ethics code, and built a website and a community of therapists who could support each other. I am proud that SIMHA still thrives.

Living and working in Shanghai gave me an amazing training in cultural awareness and sensitivity. I love learning about clients’ unique backgrounds and experiencing their worldviews. I particularly enjoy working with clients of diverse backgrounds. I am sensitive to the issues of expatriation and acculturation and generational conflicts around culture. I am also comfortable and enthusiastic about engaging with people from different backgrounds, whether cultural, religious, gender orientation, sexual orientation, or lifestyle.  It is this diversity that makes the texture of life so interesting and my work so rewarding.

Eating Disorders Evidence-based treatment Los Angeles Psychotherapy

August and September 2015 LACPA Eating Disorder SIG events

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

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

Thursday, September 17 at 7:15 pm  

Title:   Full Metal Apron: Fighting Eating Disorders from the Kitchen Table 

Presenter:  JD Ouellette   

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

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

Eating Disorders Evidence-based treatment Family based treatment Family-Based Therapy Los Angeles Psychotherapy Uncategorized

FBT Insights from the Neonatal Kitten Nursery

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.


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