Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.
Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”
This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.
Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.
When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.
Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.
While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. This has not been a high priority for researchers.
What are some advantages of externalizing the eating disorder?
It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
It puts everyone on the same team battling a common enemy: the eating disorder.
It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.
Reasons you might not want to externalize the eating disorder
Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.
Some people with eating disorders feel like the eating disorder is a part of them. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. They may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.
So, should you do It?
Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.
If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.
Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.
Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.
Parents doing FBT often struggle with “normal parenting concerns” and setting limits while doing FBT. They’re refeeding their teens at home, doing the hard work often done by professional staff at treatment centers, but they still have to parent. It’s exhausting. Their teens who have eating disorders are often experiencing the psychological and physical consequences of malnutrition while also being a teen and facing the challenges that typically come with that stage of life —social and academic pressures, family stresses, desire for more independence, and puberty.
It’s not uncommon for teens to be a little rebellious or to challenge limits. Some parents may feel they should ignore any defiance from teens in recovery or may be afraid to confront behaviors they would normally not tolerate in their children. Other parents may want to clamp down on all undesirable behaviors.
In FBT we talk about separating the child from the eating disorder and joining with and loving your child while waging war against the eating disorder threatening your teen’s life. This model may be helpful in decisions about how to parent. I recommend first trying to determine whether the behaviors you are concerned about are part of the ED or not.
This may not be obvious at first glance, but if defiance or anger or disrespectful language or threatening behavior comes out at, just before, or after meals or during an FBT appointment or a weight check—or around discussions of food, body, the eating disorder, or treatment—assume it’s the eating disorder and not your child. Remember that your child with an eating disorder has a decreased ability to regulate emotions as a result of malnourishment and that they are in a state of terror at these times. This is the fight-or-flight reaction seen during episodes of high anxiety. The eating disorder will make them lash out in hopes of avoiding the source of the anxiety (food, weighing, etc.). During those moments, I recommend speaking to them compassionately and recognizing the underlying emotion of anxiety, and not reprimanding the behavior in the moment.
During times outside of meals or treatment—which may seem few and far between for those just beginning this journey—this behavior is less likely to “be the ED.” At these times, you should parent largely as you would normally do, with the caveat that your child is under increased stress from treatment. If you would normally reprimand or give a consequence to your child for inappropriate language, staying out after curfew, or screaming at you, feel free to do so. You do not have to tolerate rudeness and defiance and can require appropriate behavior.
As you do this, do keep in mind that the intense process of recovery—including exposure to what is often 6 meals per day—is putting your child under additional stress. I like to remind parents that in many cases, teens go to residential treatment centers. While these centers have their pros and cons, one helpful aspect of residential treatment is that it removes the teen from the everyday stresses of school and home life (annoying brother, curious extended family, and heavy academic loads, etc.) so they can focus entirely on treatment. It can be easy to overlook how these stressors add up.
You might want to pick your battles so your teen doesn’t feel battered all the time. Some smaller things—like clothes on the floor of their room or not cleaning their bathroom—may need to be overlooked. You will want to prioritize addressing behaviors that affect you—for example, rude language—or that interfere with the goals of treatment, including weight gain and normalizing eating. So, if your teen doesn’t come back in time from an outing with friends and misses a snack or meal, that would be a high priority to address. On the other hand, you might choose to let go of their not going to bed on time (as long as it doesn’t keep them from getting up in time for breakfast).
If you are unsure whether the behaviors are part of the eating disorder or not and how to respond, I encourage you to consider whether their behavior is different than it was prior to the eating disorder. A normal developmental trajectory may be contributing to the changes in behavior. An older adolescent may be more challenging of authority and may exhibit behaviors that were not a part of the repertoire 6 to 9 months earlier, before the start of the eating disorder. If the behavior is different, consider whether it might be related to the stress of recovery, the result of malnutrition, or something else entirely. If it seems different and/or persists, speak to your treatment providers or have your child assessed. It may be that they have another mental health disorder that needs to be addressed. If the behaviors were there before the eating disorder, you should also talk to your treatment providers and see if additional support is needed to help you address them.
Finally, keep in mind that this is a tough time. You have a lot on your plate. Parenting and treating an eating disorder is a lot all at once. Try to separate your teen from their eating disorder and develop a list of priority behaviors to address so you don’t take on too much at once. Talk to your treatment team about your concerns. And remember you don’t have to abdicate all parenting just because you are also on their treatment team.
Two of my favorite teen parenting books:
Get Out of My Life, But First Could You Drive Me & Cheryl to the Mall?: A Parent’s Guide to the New Teenager by Anthony E. Wolf
Parenting Teens with Love and Logic: Preparing Adolescents for Responsible Adulthood by Jim Fay and Foster Cline
We are excited to announce that via our designation as a practicum site we are now able to train advanced graduate students in psychology in evidence-based treatment for eating disorders. This allows us to further our mission of helping to disseminate evidence-based treatments and to bring them to people in Los Angeles County who need them. We are also able to offer a true low-cost treatment option. Our psychology externs will be able to provide individual psychotherapy for adults with bulimia nervosa and binge eating disorder and teens and adults with disordered eating and body image concerns.
Beginning in August, 2021, the cost for sessions with our psychological externs is $60 per therapy hour. We will also be offering some lower-cost groups. Sessions are available in-person in our office in mid-Wilshire area of Los Angeles and virtually with individuals throughout California.
As of June 2021, EDTLA has developed a memorandum of understanding with two local doctoral programs in clinical psychology— the California School of Professional Psychology at Alliant International University and Pepperdine University’s Clinical Psychology Doctoral Program of the Graduate School of Education and Psychology.
Each year, up to two advanced-level doctoral students are carefully selected through an interview process to be psychological externs at EDTLA. Psychological externs provide individual and group therapy to adults and adolescents.
All of the psychological externs receive extensive training through EDTLA’s training seminars and supervision program in order to provide quality therapy at lower fees than is typically found in Los Angeles.
All Psychological Externs work directly under Dr. Muhlheim (PSY15045), meaning that treatment decisions and progress are monitored on a weekly basis by an experienced licensed psychologist.
To inquire about receiving treatment from one of our psychology externs, please complete this form (and put Psychology Extern) under “Requested Clinician.”
You can read more about our current psychology externs here.
There’s an eating disorder that often gets overlooked amongst the better-known eating disorders like Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. Avoidant Restrictive Food Intake Disorder (ARFID) is an eating disorder that can involve difficulty tolerating certain foods due to textures, tastes, or smells. It can also manifest as avoidant behaviors stemming from a trauma around food such as choking or getting sick from eating a particular food. Some people worry about whether they are going to be able to swallow food or they have an aversion to throwing up. ARFID can present as a lack of interest in food altogether.
This eating disorder can result in very limited food selections which in turn can lead to medical complications such as low weight, failure to gain weight during childhood, developmental delays, malnutrition, and vitamin and mineral deficiencies. Many people who struggle with this disorder share how uncomfortable it is to eat out socially and feel isolated from peers and family. It can be a very frustrating disorder for the individual who has it and certainly can be difficult for the caregiver or loved ones supporting a person struggling with ARFID. Many people who have ARFID do want to eat. Unlike people with anorexia nervosa and bulimia nervosa, people with ARFID usually do not have fears of weight gain or their body changing.
It can be hard to sit across the table from someone you love and see them unable to feed themselves even when they are hungry. It can be hard to understand and relate to a person with ARFID’s lack of interest in eating or fears that arise around certain foods. Many times caregivers find themselves accommodating meal times by cooking specifically for their person with ARFID or having to plan out exactly what foods will be available to eat when away from the home.
How do you support the person you love as they are trying to recover from this eating disorder?
First off, validation. The recovery process can be really hard. For many people with ARFID doing food exposures is an important element of treatment. This means they are trying foods that they have been terrified of eating or practicing eating to prove their fears are not coming to fruition. It is a scary process to face these fears. They may feel anxious and overwhelmed. Let them know that what they are feeling is real. Validate their feelings. Acknowledge how tough this must be for them, and share that you believe they can do it.
Second, have patience. ARFID is often seen in children but can last well into adulthood. Many of my own clients have been restrictive eaters since they were babies and toddlers. For years families have found ways to feed them and that often involved negotiating with what they would eat and sticking to these safe foods. You may have found yourself making separate meals for your family member and not going to certain restaurants because you knew there were no food options for them to eat. As your loved one begins to do exposure work with foods it will take time for them to become more comfortable. You may want to say, “Just eat” or get frustrated by their continued refusal. Remember that expanding their food variety is a slow process. Pressure and anger are not helpful. In fact, they may be shaming. Encourage your loved one to practice trying new foods every day. Remind them the more they practice the easier this will become.
The third thing that is helpful is allowing them to have agency when it comes to their food choices. People are more likely to try foods that they are interested in versus feeling compelled to eat a food when they do not want to or are not willing to try it. The process can feel less intimidating. As a parent, you may find yourself in less of a power struggle with your child if in the past they have held up strong resistance to tasting new foods.
Fourth is education and support. It can be very powerful to learn about ARFID and its symptoms. It may also be helpful to reach out to other caregivers who have gone through this process. Many parents feel helpless when their child refuses to eat. Having support from a therapist, support group, and medical providers can feel empowering and also help relieve some of the burdens you may be placing on yourself.
If you or someone you know is struggling to eat due to aversions or fears there is help available. Checking in with your medical professional first can be a good place to find out if your loved one is under-weight, has deficiencies from lack of nutrition, or is experiencing any other health complications. At Eating Disorder Therapy LA, I and other therapists have been trained in helping ARFID patients recover. There is hope–and recovery from this diagnosis is very possible.
If you have an eating disorder, or your child has one, there is a good chance that weight gain will be an essential part of the recovery process. This is true not just for people in objectively small bodies, but also for people in larger bodies who are diagnosed with Atypical Anorexia, a weight-biased diagnostic category included in the DSM-5. It is even true for people recovering from bulimia nervosa and binge eating disorder.
The eating disorders field lacks consensus on how to set recovery weights. I know a respected professional who argues adolescents should be routinely restored only up to the 25th percentile weight for age. They argue that this reduces their potential for experiencing weight stigma and reduces their anxiety. However, I see a problem with this, as do many of my colleagues and many families and recovered people.
This article discusses why weight recovery is a priority; what the research on weight suppression says; how we use growth curves in setting recovery weights; what evidence suggests that many providers set recovery weights too low; and how this applies to people in larger bodies.
Why Prioritize Weight Recovery
We know that while weight recovery in anorexia is not sufficient for recovery in and of itself, it appears to be a prerequisite for full psychological recovery. Eating disorder cognitions as well as most of the physical symptoms appear to recede only with full weight restoration. Food is medicine not just for the body, but for the brain as well. That is why we often say, “Food is medicine.”
The research on timelines for eating disorder recovery show that remission of eating disorder behaviors such as binge eating and purging takes an average of eight or nine months, and weight recovery takes on average 12 months. But it takes even longer to end eating disorder thoughts, including the preoccupation with shape and weight and urges to restrict, purge, or exercise. These thoughts can persist for nearly a year after a person has reached a normal weight, has stopped engaging in behaviors, or both.
Weight Suppression and Negative Energy Balance
We also know that weight suppression—defined in adults as the difference between a person’s current weight and their previous higher adult weight—predicts continuation of eating disorder symptoms including binge eating. In children and adolescents, weight suppression would be defined as a negative deviation from one’s expected weight curve (more on growth curves below). Therefore, at EDTLA we prioritize full weight restoration for all patients in all body sizes and with all eating disorders. Failing to fully restore a person to their recovery weight for body and brain could prevent them from a full recovery.
A negative energy balance—taking in less energy than one’s body needs—may be a primary contributor to the development of an eating disorder in someone who has the innate susceptibility. Cindy Bulik, Ph.D. describes how a negative energy balance lowers anxiety for a person with this vulnerability, creating a trap. Restriction becomes seductive under these conditions. Couple this with the evidence that the weight loss leading to the development of anorexia nervosa could be unintentional—such as a side effect of an illness or an overexpenditure of energy for sports combined with undereating. Together these suggest the best defense against relapse is maintaining an adequate energy balance and a healthy weight where the brain is functioning well enough to not act on residual thoughts.
Using Growth Curves to Estimate Recovery Weights
In this section, I will discuss why using individual growth records is so important. We have received guidance from our colleagues specializing in adolescent medicine and eating disorders. Like many eating disorder dietitians, one of the things we do is look at childhood growth records when they are available. This method is more tailored than using population averages such as BMI to set recovery goals.
In the US, most pediatricians and family medicine doctors document children’s growth on the CDC growth chart, which plots height, weight, and body mass index (BMI) against age-based averages. In healthy children and teens, height and weight each increase along a consistent growth curve. Some children and teens grow steadily along the 95th percentile, some along the 75th percentile, some along the 50th percentile, and still others along the 25thh percentile.
But not every body is the same, and it’s normal for individuals’ height and weight to follow different growth curves. For some children and teens, a weight along the 75th percentile and height on the 25th percentile is normal. This defines the growth curves for that individual. Just as not every woman of average height wears a size 8 shoe, not everyone of average height is meant to be at the 50th percentile for weight. There is always a normal distribution in a population. These growth percentages appear to be largely genetically determined.
A deviation on an individual’s growth curve for weight, height, or BMI—even in the absence of actual weight loss—may indicate there is a problem such as an eating disorder. A child should be growing and gaining weight during this time, so the failure of a child or teen to gain the appropriate weight can be equivalent to weight loss. This means that when there is actual weight loss, the amount of suppression—the difference between current weight and where one should be on a growth trajectory—is usually even greater than the actual pounds lost.
Thus, a parent may come to us and say, “My child has only lost 10 pounds.” However, when that weight is plotted and we notice that the child also failed to gain any weight in the months before they lost weight, we might now look at their curve and see that in fact, the child should gain 20 pounds (or more!) to catch up to where they should be on their own unique growth curve. Some kids may not have lost any weight at all—but have fallen short of their appropriate gain for so long that they now should gain at least 10 pounds.
This is why we also often say that weight is a moving target. To remain in recovery, a year from now an individual’s goal weight must be higher than the weight that would be healthy at their age today. And this is true even for children who are no longer getting taller, as it is normal for weight to continue to be gained through about age 20.
Please be aware that some non-ED specialist pediatricians/health professionals may not be well-informed about this individualized process of setting goal weights. I once had a pediatrician who told a teen’s parents she would be happy if my patient got to a certain weight because that was the weight that the pediatrician—who was herself quite petite—had weighed at the patient’s age.
What? A pediatrician setting a goal weight for a patient based on her own unique growth history!?? When you take your clothes in for alterations, does the tailor cut the clothes to fit the tailor? Do you see the problem here?
Speaking of growth curves, the use of growth curves to spot early eating disorders is an underutilized practice. In a recent study on pediatric patients hospitalized with an eating disorder, 48% of patients experienced a deviation in the growth curve a median of almost 10 months prior to the first eating disorder symptoms being reported by parents.
We will also show you how your teen’s weight should be tracking on the weight curve. Teens generally gain 30 to 40 pounds in the course of puberty. While many children gain weight and grow naturally during this period, we find that children who have had an eating disorder may need continuing guidance to help their weight keep pace with their age and height. We encourage parents to keep an eye on their teen’s weight to make sure weight continues to track along the expected curve. We respect parents and educate them on this.
At EDTLA, we do our best to challenge our own weight biases and that of our patients and their families. We believe that facing the anxiety of a patient or a child restoring to a slightly higher weight has benefits that outweigh the costs. We help the family challenge the belief that being fat is worse than remaining ill. I never want to be the provider who set a goal weight so low that it contributed to prolonging a mental illness from which it may take a patient 9 to 22 years to recover.
Challenging weight bias and setting higher weights goals does not always make us popular. Teens with eating disorders are by definition, terrified of gaining weight. In her blog, eating disorder specialist pediatrician Julie O’Toole discusses the setting of goal weights and how parents fear that too much weight gain will make their teen more depressed and anxious. Dr. O’Toole emphasizes the importance of basing treatment goals on data rather than placating the eating disorder.
Remember that an irrational fear of weight gain is often a symptom of the disorder. The anxiety over one’s body size often improves significantly with recovery, which requires more regular eating patterns and—ironically—weight gain. Please note this is rarely immediate. It may take up to a year of being at one’s healthy weight and learning to tolerate a changed body before the eating disorder thoughts fully subside. On the other hand, appeasing the fear of gaining more weight can maintain the fear and potentially the disorder.
How Does This Apply to People in Bigger Bodies?
We are often asked why a person who has historically been at a higher-than-average body weight must be returned to a weight that is higher than average. We recognize that bodies naturally come in a variety of shapes and sizes. Some people are meant to be larger. We often encounter patients and families who say “but they looked better when they were a few pounds less” and want to use the eating disorder as an opportunity to keep a person’s weight suppressed. We believe that using an eating disorder as an opportunity to avoid returning to a previous higher weight could hinder the individual from reaching full recovery. And the research on weight suppression supports this. In the words of Julie O’Toole, “Rarely can a child who is genetically programmed to be larger than average be safely held at a ‘thin’ body weight. Size acceptance may be a part of the family’s treatment challenge.”
Of Course, Recovery is About More Than Weight
Remember, though, that an estimated recovery weight is just that—the best estimate of where recovery will occur. I think it is important for parents to have a roadmap and to know generally whether they might be needing to add (at least) 10 pounds or 20 pounds or 40 pounds because it gives you a realistic expectation of how long the weight recovery phase may take. Again, this may change over time and our estimates are usually a minimum weight and bodies may go higher.
Ultimately, recovery is about state, not weight. And recovery means more than just weight recovery. We are looking for recovery of physical health—normalization of heart rate, blood pressure, and body temperature and resumption of menses when appropriate—as well as psychological recovery which includes improved mood, decreased eating disorder thoughts, return of normal hunger cues, and more regular eating, a less fraught relationship with food, improved social functioning, and a return of interest in other age-appropriate activities.
In one informal survey of 29 parents whose teens were given a recovery goal of 19 BMI, most reported recovery actually occurred at a BMI of 23 or greater and none achieved recovery at a BMI lower than 21. Parents will report that often, with an additional ten extra pounds, their teens were more likely to attain state recovery. If someone is not doing well at what we initially estimated to be a recovery weight, we will review that and may suggest after a few months that we raise the goal weight a little.
This post has described our thinking, which is informed by research, parent feedback, and expert opinions by leaders in the intersection of adolescent eating disorders, FBT, and Health at Every Size ®. We hope it helps you understand our recommendations.
But you don’t have to take our word for it. We invite you to do your own research. Below we’ve compiled some resources from leaders and colleagues in the field. And we strongly suggest you watch this video by Eva Musby.
Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.
Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.
Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”
As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.
In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.
In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.
The Challenge of Environment
In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.
We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:
Having friends or relatives over for dinner
Eating at a close friend’s house
Eating at a restaurant where individual entrees are served
Eating at a family-style restaurant
Eating at a buffet.
Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.
Take it Slow
Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.
More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:
Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
Cooking for oneself
Going to unfamiliar restaurants
Eating at a small-plates, buffet, or family-style restaurant
Foreign travel to countries where the foods may be entirely unfamiliar
Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:
Having meals planned out for the entire week
Eating meals at regular times
Regular grocery shopping
Having a backup plan (in case you run late or a plan changes)
Always carrying snacks (and backup snacks)
Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
Limiting meals at unfamiliar restaurants
Only bringing into the home small quantities of foods on which you have binged
Having a support person you can call
Structured schedules for every day of the week, including weekends
Careful planning ahead (with your team if you have one) for any situation you have not yet practiced
Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.
When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.
In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team can also include a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.
It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.
So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.
FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.
Comprehensive Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.
Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.
For DBT to by comprehensive it must comprise the following components:
DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.
When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.
Exposure and Response Prevention
Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.
OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.
As of March 2020, the advent of the COVID-19 pandemic is bringing dramatic changes to all aspects of our lives.
One of the most significant impacts of social distancing is a change in the mode of delivery of psychological treatment. It appears that most outpatient therapists, dietitians, and medical doctors are moving entirely to telehealth sessions (over the computer). Even many intensive outpatient (IOP) and partial hospitalization (PHP) programs appear to be shifting to a telehealth delivery model. Further, it appears that admissions to residential treatment centers may be reduced and limited to only the most severely medically compromised patients.
As a result of more stringent admission standards as well as travel restrictions and the transition to online sessions, it appears that a larger number of eating disorder patients will be in the home. Fortunately, Family-Based Treatment (FBT) is a treatment naturally poised to fill the gap created by the Coronavirus.
FBT has emerged as a leading therapy with empirical support for the treatment of adolescents with anorexia nervosa who are medically stable. It also shows support for adolescents with bulimia nervosa and young adults with anorexia nervosa. FBT makes the role of parents central to challenging their adolescent’s eating disorder. The hallmark of the treatment is family meals which parents plan, prepare, serve, and supervise. If purging is an issue, they supervise after meals. They implement strategies to prevent purging, excessive exercise, and other eating disorder behaviors. I have often said that FBT is like providing residential treatment in your house for only your child.
FBT is a manualized treatment and usually takes place in approximately 20 weekly sessions with an FBT therapist over a period of about 6 months. A teen should also be monitored by a medical doctor and a dietitian may be involved in helping the parents with meal planning. Fortunately, FBT sessions can be delivered via telehealth.
Telehealth is the delivery of medical or mental health treatment over live video. There are numerous HIPAA-compliant platforms that treatment professionals use such as Doxy, Zoom, and Vsee. Aside from a reliable internet connection and a private setting, there are no additional requirements for telehealth delivered mental health care. Telehealth interventions have been used in various forms since 1972. In general, the research shows that therapy delivered via telehealth can be effective for a variety of problems. Telehealth has been successfully applied to both family therapy and the treatment of eating disorders.
Kristen Anderson, LCSW and colleagues did a study of FBT for adolescent anorexia utilizing telehealth. They utilized the same treatment manual utilized in outpatient studies of FBT with minor variations. For example, instead of weighing the patient in the therapist’s office prior to appointments, the parents weighed the patient at home prior to the session and shared the weight with the therapist. The structure of the sessions was the same, with all family members in attendance. The therapist initiated therapy sessions by video conference and met individually with the patient for a few minutes first, followed by a meeting with the entire family for the remainder of the therapy hour.
Anderson and colleagues found that it was feasible to deliver FBT via telehealth. There were no dropouts over the course of the study and the average number of treatment sessions attended was 18.4. Parents found the treatment to be extremely helpful and participant weight increased significantly. Meaningful improvements were also noted in eating disorder symptoms as well as depression and self-esteem. Anderson and colleagues concluded, “these findings suggest that this method of delivering FBT may be effective for meeting the treatment demands of adolescents living in areas of the country where there are inadequate treatment resources such as nonurban or rural settings.”
Little did they know that throughout the world, social distancing would create a need for FBT delivered by telehealth!
If you are looking for virtual FBT support during this time, we can support families throughout the states of California, New York, and Florida in the US, and we can also provide support for families in some other countries. We use a secure online platform. Please ensure you have a stable internet connection and try to position the video so that all members of the family are in view of the video screen. Learn more about our telehealth services.
If you are looking for FBT by telehealth in other states and countries, please check out the following websites:
Family-Based Treatment (FBT) is the leading evidence-based treatment for adolescents with anorexia nervosa and bulimia nervosa. One of the common misbeliefs I hear is that it’s “only for kids or younger teens.” However, I think it has a much wider applicability. In fact, I would say that my FBT training has significantly improved my effectiveness in treating eating disorder patients of all ages.
While there have not been studies of FBT that pull it apart and pinpoint the elements that drive its success, I have a few theories. One of the key underpinnings of FBT is meal support. People with eating disorders experience such crippling anxiety before, during, and after meals that it is no wonder they would do anything they can to avoid eating. When the brain is in a state of overwhelming anxiety, a person with an eating disorder cannot make logical decisions about what to eat—or even to eat. And yet, without eating there can be no recovery. Treatment centers understand this—providing regular meals has been the mainstay of residential and partial hospitalization (PHP) eating disorder treatment for some time. FBT is the in-home parallel to this treatment.
In FBT, parents are charged with nourishing their teens back to health by providing regular nutrient-dense meals and preventing purging, excessive exercise, and other eating disorder behaviors. Parents plan, prepare, serve, and supervise meals and after meals, if purging is an issue. They make all the food decisions. They sit with their struggling child during those terrifying meals and help their teens cope with eating amounts sufficient for them to get well. Over time they return control to their teens, building their capacity to fight the eating disorder on their own. It takes effort and time to change brain pathways that have made eating a scary experience. For this reason, even those patients with eating disorders who go on to higher levels of care usually don’t remain there long enough to develop the autonomous ability to eat enough to sustain recovery. They often continue to need meal support for some time after more intensive treatment.
I think FBT has applicability that spreads wider than just children and teens. There is preliminary evidence of its successful use with transition-age youth up to age 25. Many parents have reported successfully using it with their college-age children. I have used it with this age and the primary variation is that the young adult plays a bigger role in their own treatment. They must agree at least in theory to accept their parents’—or other caregivers’—support. The young adult may choose who will support them during meals. Some, for example, may have a college roommate provide support. Some parents do meal support via FaceTime when the young adult lives far away.
I should clarify that FBT is a manualized evidence-based treatment. To be done with fidelity it must comprise certain components, including a therapist who guides the parents in organizing their strategies to fight the eating disorder. Parents refeeding their child without a therapist’s oversight often state they are “doing FBT”. In this case, it is more accurate to say they are providing FBT-informed or carer-supported feeding. Regardless of the words we use to describe this support and whether or not a therapist is involved, I think it provides a core benefit that we can expand to other populations.
These principles can also be applied to adult treatment. I personally have supported an adult who was in PHP during the day and needed more support with meals outside of treatment hours. I applied the skills I learned in my FBT training to provide meal support to this person. It worked just like it did with teens. Obviously this adult was an active participant in their recovery who asked for my support. This does not mean that I did not encounter the same kind of anxiety and resistance that parents meet around meals.
Take another case —a 20-something patient who still lives with her parents. She has been doing so much better since she asked for help, trading in the restrictive foods she had been eating on her own for several years for family meals prepared by her parents. Or the case of a college student who gets support via FaceTime from her parents who live in another city. When working with young adults with eating disorders who are in loving relationships, we often work to help their significant others develop strategies to support them during meals.
My experience is not unusual. Many other FBT-trained clinicians report success with providing FBT-informed treatment to people from all walks of life. One dietitian has reported great progress working with an employed single adult who moved home to live with his parents so they could support with meals. Sadly, previous providers had pathologized his moving home as a sign of enmeshment. One therapist shared, “I am doing FBT with a 79-year old. She is now in phase 2. She can now go out on dates—she just has to send pictures of her food to her adult children who are taking charge of her recovery and have been in charge of plating her food.”
Many have realized that in-home meal support is a common need for patients, and naturally, it is starting to become a big business with several treatment programs now providing this service. Offered as a service, this individualized meal support can be very expensive. Far more convenient, cost-effective, and loving is meal support provided by parents, other family members, or significant others.
I personally see it as a sign of strength when an adult admits they need more help. There is no shame in needing meal support during your recovery no matter what your age. Moving back home to live with family for support is nothing to be embarrassed by. This disorder robs people of their ability to make decisions around food—outside support is needed by definition. If you struggle around mealtimes with deciding what to eat, only feel safe eating a narrow range of food, have been struggling to make progress in your recovery, or cannot manage urges to purge after eating, you are not alone. You may benefit from the addition of meal support. It may feel scary or embarrassing to ask for help and you may worry you are being a burden. But asking for help is a brave step and you will likely find that there are some people in your life who can do this for you. It sometimes requires a little creativity, but you may find that it makes a big difference in your recovery.
The short answer is: FBT can be for people of any age.
Chen, E. Y., Weissman, J. A., Zeffiro, T. A., Yiu, A., Eneva, K. T., Arlt, J. M., & Swantek, M. J. (2016). Family-based therapy for young adults with Anorexia Nervosa restores weight. International Journal of Eating Disorders, 49(7), 701–707.
Dimitropoulos, G., Freeman, V. E., Allemang, B., Couturier, J., McVey, G., Lock, J., & Le Grange, D. (2015). Family-based treatment with transition-age youth with anorexia nervosa: a qualitative summary of application in clinical practice. Journal of Eating Disorders, 3(1), 1.
Dimitropoulos, G., Landers, A. L., Freeman, V., Novick, J., Garber, A., & Le Grange, D. (2018). Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(1), 50–61.
On September 18th, 2019 Instagram instituted an official policy that all ads promoting diet and weight loss products would only be able to be viewed by users 18 and over. Any ads that have false claims can be reported and subject to removal. This is a huge victory in the world of challenging diet culture. For years, celebrities and social media influencers have been advertising diet and weight loss products that, for the most part, are bogus, promise false results and can be just downright dangerous to someone’s physical and mental health.
Most celebrities who promote these products are doing so for a paycheck and not because they are actually finding these products useful. Unfortunately, advertisements like these can impact impressionable viewers, especially those struggling with poor body image, disordered eating and eating disorders. And while the celebrities may say, “Take this and look like me,” the reality is that these products have no true evidence that they can change anyone.
Emma Collins, Instagram’s public policy manager, made a statement after this policy went into effect, “We want Instagram to be a positive place for everyone that uses it and this policy is part of our ongoing work to reduce the pressure that people can sometimes feel as a result of social media.” While this is a great step forward, it does feel like the next step should be eliminating diet and weight loss products altogether.
There are some major problems with advertising weight loss products. As a Health at Every Size® activist and promoter of body positivity, I can tell you that these products merely reinforce the idea that your body isn’t good enough. They teach that there is only one ideal body, and usually, it is the body of the celebrity promoting the product. It can be really dangerous to tell people that tea will flatten their stomachs or a lollipop will give them curves in the “right” places.
These advertisements put people at risk for developing eating disorders. They promote the very behaviors that are symptoms of eating disorders. These products try to normalize appetite suppression or compensating for what one has eaten via a laxative pill or tea. The messages are not health-promoting. They reinforce diet culture beliefs of certain foods being bad and needing to atone for eating.
A major issue is that there is absolutely no evidence that the products being advertised actually help with weight loss, detoxing your body of toxins, or changing the shape of your body. Most of these products are not even approved by the United States Food and Drug Administration (FDA). The FDA is charged with regulating medications and while there are a few that have been approved, most that are advertised on social media are not. Most of these products carry false claims and use ingredients that can be more harmful than helpful. And that is a huge problem.
We do not often see celebrities sharing disclaimers of potential side effects from using these products. Diet pills may increase heart rate, heart palpitations, the likelihood of a stroke, and even death. The detox teas carry the risk of dehydration, electrolyte imbalance and stripping our guts of the nutrients we need. Side effects can also include an increase in stomach cramping, bloating, and diarrhea. Our bodies were designed to naturally flush out toxins. It is why we have a liver. And for those users of the products looking for a way to lose weight, well the weight “lost” from these teas are usually just water or stool mass. These products place a huge toll on the body and put vital organs at risk.
For these reasons, we should not only be protecting social media users who are under 18. We should be protecting everyone from viewing these ads. Adults are probably more likely to purchase these products and adults are just as susceptible to false promises as adolescents. It is great that places like Instagram are giving us a choice if we want to view these ads. It is definitely a step in the right direction. But, there is nothing safe about these products. From taking a physical toll on our bodies to mentally placing shame on our bodies there is no room for diet pills, detox teas, or any other weight loss product.
If you are currently struggling with how you feel about your body, help is available through support groups, therapy, and even body-positive accounts and groups on social media. The wonderful thing about social media is that there is a community for promoting Health at Every Size® and working on self-love and acceptance. Most of these groups do not cost anything and can have to have positive effects on your mind and body.