The holidays are a challenging time to navigate for most people. The holidays are even more challenging for those who struggle with their relationship with food. As we prepare for the holiday feasts and festivities, there are a few things to consider, especially when you have a child or other loved one with an eating disorder. While this list is not all-encompassing, it can serve as a thoughtful reminder to be aware of the challenges others may face this holiday season and some strategies to support them.
Things to Do
Plan ahead. With the holiday season ahead of us, the best thing we can do to support someone struggling with an eating disorder is to plan ahead. Planning ahead includes identifying what could be triggering for your child and developing strategies to deal with these triggers appropriately. Here are some common holiday triggers to consider: buffet-style eating and a surplus or different types of food, expectations from others, comments about food choices and appearance, comments about being overly full or eating too much, fasting for religious reasons, etc. One of the best ways to plan ahead is to talk to your child about what they are most worried about for the upcoming holidays.
Talk about the holidays and traditions that have been triggering in the past. Part of planning ahead is knowing and understanding what your child is anticipating to be anxiety-provoking. One way to identify potential triggers is to ask what was challenging about the holiday in previous years. While your child may be doing better or even be in recovery, holidays pose many challenges that your child may not have practiced in treatment yet. If any specific holiday foods are triggering, this is an excellent time to start practicing with these foods. Your child’s therapist or dietitian can help plan exposures to fear foods.
Ask what support your child needs from you or others. What does your child anticipate needing from you during the holiday season? The conversation about support is part of planning ahead. Some ways you can help support your child include: steering conversations away from talking about food and appearance, making a plate for them (if that help is needed), helping with coping skills before or after meals (discussed later), etc.
Model appropriate eating. While there may be adults and other children around the dinner table who are engaging in dieting or disordered eating, having your child have a good role model will be helpful. Appropriate eating does not mean you have to eat exactly what your child is eating. Appropriate eating means honoring your hunger and fullness cues, choosing a variety of foods, and demonstrating enjoyment of your meal.
Provide distraction or additional support during or after meals. As discussed above, one of the most supportive things you can do is help your child cope effectively. It can be helpful to ask your child what coping skills work best and practice these skills before the holidays. Rather than rushing from one activity to the next, provide time for your child to regulate their emotions. Distraction can take many forms, so you can get creative and plan for things that will engage your child. Some of the best distractions include things that require extra mental effort, such as a game of Scrabble or Bananagrams. Other distractions include watching movies or TV, playing with the family pet, board games, arts/crafts, etc.
Prepare other family members (and set up a family session if possible). Recovery takes the support of many people. While you, as a parent, may know the most about your child’s eating disorder and how to best support them, having others learn how to support your child can be helpful. Preparing other family members can include setting boundaries with specific conversational topics, such as diets and the appearance of others. It can also involve having others help support your child during or after meals or navigating other conversations that may be anxiety-provoking for your child. If your child is in treatment, this is a great time to request a family session to help plan ahead for the holidays and elicit extra support.
Have conversations when you notice eating disorder behavior. The holidays are challenging. You will likely notice increased anxiety or some eating-disordered behavior. While it may feel overwhelming to discuss these behaviors with your child in the moment, it is important to address them. To discuss behavior you are noticing, you should talk to your child away from the meal or anxiety-inducing situation (i.e., the meal, conversation, person, etc.) and then discuss what you are noticing and ask how you can help support them (or suggest a coping skill if your child is overwhelmed).
Things to Avoid Doing
Don’t make comments about appearance. It is never helpful to comment on your child’s appearance or the appearance of others. During this time of recovery, your child is likely hyper-fixated on their appearance and is likely engaging in social comparison more frequently. Due to the preoccupation with thoughts about body weight and shape, it is best to steer the conversation away from how someone looks. Instead of discussing appearance, you can model interest in other characteristics such as hobbies, school or work, or other passions of the person.
Don’t make negative comments about food or food choices. It can feel natural to say things like “I am so full,” “I overate,” “I can’t believe I had another piece of pie,” and other comments after eating. However, your child is listening and likely internalizing comments like this. It is important to note that when comments like this slip, you can correct them. If you or anyone else makes a comment like this, you can say something like, “while I am full, I enjoyed my meal,” or change your narrative to something more neutral.
Don’t expect your child to eat or try everything. While your child may be doing better or be in recovery, the holidays or certain food served at the holidays are likely triggering. Your child should still eat their meal plan, but they should not be expected to try everything. Part of planning ahead can include discussing what their plate should look like based on their meal plan. If your child needs to eat before or away from the guests, arrange for that to happen to ensure they complete the meal.
Your child should still follow their meal plan (i.e., 3 meals and 3 snacks). While some people engage in restriction before a holiday meal, your child should still eat all meals and snacks as indicated by their meal plan. It can be helpful to discuss and meal plan with your child’s therapist and dietitian before the holidays.
This holiday may not go perfectly. Spend time identifying what went well, and times you noticed that they used coping skills.
Holidays are stressful for most people. As a parent of a child with an eating disorder, ensure you also take time to engage in self-care.
As we have written elsewhere, we believe Family-Based Treatment (FBT) is a complete treatment for teens with eating disorders. Most teens will not need (or want) additional therapy. The one area where we think teens could use a little more support is in developing a strong anti-diet stance to stand up to weight stigma in our fat-phobic society. Teens who are in family-based treatment may also not have any interaction with peers who are also working towards recovery. Community in recovery can be a powerful support if teens are motivated and working together.
To fill these potential gaps in FBT we have developed a group to supplement FBT and help put a strong anti-diet finish on the treatment. This group is for teens of all genders in California, ages 13 to 18, who are in Phase 2 of FBT and are weight recovered and abstinent from eating disorder behaviors. Teens who are not in treatment with us, but who show similar signs of recovery will be assessed for readiness for our group.
The group is 6 weeks and is held on Tuesdays from 5:00 to 6:15. The group aims to help teens in recovery develop connections and build a strong anti-diet HAES (R) stance. The group explores how media messaging, diet culture, and weight stigma impact body image through a Health at Every Size (R) -informed approach. Teens will be able to share and connect through discussion, art, and advocacy, all while developing strategies to promote empowerment and body acceptance.
Feedback from participants has been positive. Teens have shared that it has been helpful to connect with other teens who have shared the same struggles and support each other in standing up to diet culture. They have also found the educational component helpful and take away strategies to continue to support their recovery.
The group is led by Lauren Barker, LMFT who has a lot of experience with this population. Space is limited. This group is offered several times a year. Next projected start date is September 13th.
Pricing: $270 for 6 weeks. Or in-network for teens with Anthem, Aetna, Anthem medi-Cal, and Beacon Partners health insurance
To register or for more information, email Hello@EDTLA.com and put “teen girl group” in the subject line.
We welcome parents of youth 10 to 20 with Avoidant Restrictive Food Intake Disorder (ARFID) to our virtual support group.
Parenting a young person with ARFID is challenging. Feeding a young person with ARFID is extremely challenging. Meals may feel like a constant struggle. You have likely been given conflicting advice about whether to cater to their food preferences or not. You may feel like you’re running ragged searching for their preferred brand of yogurt or chicken nuggets or having to bring home the exact right fast food every night. You may have run out of ideas for what to serve them. They may be eating the same eight foods over and over again and the list of foods they are willing to eat only seems to get smaller over time. You feel worried about their health and you know they are not getting enough nutrition.
This monthly group is alternately led by Lauren Muhlheim, Psy.D., CEDS-S and Carolyn Comas, LCSW, CEDS-S over zoom. We will provide psychoeducation about ARFID, the different types of ARFID, how it may develop, maintaining factors, and recovery strategies. Parents will be able to share struggles and successes.
For more information about the group, please contact Hello@EatingDisorderTherapyLA.com or you may register for the monthly group (priced at $30) on our group page. (Please be sure you are registering for our monthly ARFID Parent group and NOT our free weekly Adult ARFID group.
Below are some strategies for supporting your teen with ARFID:
When I am working as the Family-Based Treatment (FBT) therapist for a teen in recovery, their parents will often ask whether the teen should also see a therapist individually. Unlike other therapy situations, in FBT there is no expectation that there is both an individual therapist and a family therapist. It’s there in the name: “Family-Based Treatment.” FBT is not just “family therapy” aimed at solving family problems—it is a specific, comprehensive, evidence-based treatment. In fact, the developers state that they called it Family-Based Treatment when they were manualizing the approach because they wanted to distinguish it from being viewed as a type of family therapy.
As I have stated elsewhere, I think most teens who receive FBT will never need individual therapy for an eating disorder. I actively discourage the addition of an individual therapist in Phase 1 (nutritional rehabilitation). When we arrive at Phase 2 (handing back of control to the teen), we can better assess which issues remain unresolved with weight restoration. This is the point at which the adolescent is likely to be more receptive and able to benefit from individual therapy. Even here, I think additional therapy is only needed when there is a specific additional diagnosis or specific problem. Adding an individual therapist when one is not needed adds risk and can even undermine the FBT.
Among the reasons I discourage adding an individual therapist in Phase 1 is that the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, in one case series of families with “failed FBT”, does not believe in or support FBT. Additionally, in one case series of families with “failed FBT” teens later admitted asking for individual therapy as a deliberate strategy to exclude their parents and reduce the pressure for weight gain. I have observed teens who ask for individual therapists in Phase 1 and by Phase 2 no longer make such a request.
Reasons parents sometimes cite for wanting their teen to have an individual therapist include processing the underlying issue and having someone to listen. I do not think these are valid reasons for adding an individual therapist during Phase 1, given the risks that it could deflect from the focus on nutritional restoration. And, as discussed elsewhere, there is not usually an underlying issue to process.
Curious where other providers stand on the issue, I asked a few colleagues under what circumstances they would add an individual therapist in Phase 1 of FBT. These were their replies.
Never, if there isn’t a comorbid issue. I would not ever add an individual therapist to address the eating disorder during FBT treatment. The only time I do it is for some kind of comorbid issue, and even then, I usually don’t do it during phase 1. – Natalie Wingfield, LPC
I strongly discourage it and talk a lot about fidelity to treatment, commitment to the program, and how we want to ensure they are getting the full benefits of FBT. I also talk a lot about lack of research support for adding a therapist and the potential for therapy burnout from seeing multiple providers. But, I’ve had some families where they were very resistant to pausing individual work and I thought a lot about the cost/benefits of them not getting any eating disorder treatment if I remained rigid in my stance. In those rare circumstances, I’ve had success in asking to talk to the individual therapist about the treatment and role delineation/expectations. In my experiences so far, this has resulted in the other therapist either voluntarily pausing their treatment in support of FBT or really good communication between myself and the other therapist to help prevent mixed messages. I could definitely see it going sideways though and it’s not something I casually agree to with families. And it’s always a red flag to me when families won’t back down because it usually means they will be asking for additional changes to the treatment and will struggle with the structure. – Amy Henke, Psy.D.
I wouldn’t for the reasons stated above and more. If they are in phase 1 and therefore undernourished, they are not likely going to be able to engage productively in therapy anyway. I can see a lot of processing how difficult phase 1 of FBT is, and expressing a ton of distress which naturally most therapists would feel compelled to solve. This could only lead to the individual therapist interfering in the FBT process or at the very least introducing doubt about its usefulness to the client and family. Overall, “0/10 would not recommend” is my stance. I think it also confuses the idea that renourishment is really the key to resolving many of the presenting behavioral and psychological symptoms. If one therapist is talking about regular meals and the other is talking about self-esteem, 9 times out of 10, an overwhelmed parent is going to pick self-esteem as the issue to address. Then we risk losing the client to something that is not going to help them. – Christine Knorr, LCSW, CEDS
Usually I don’t recommend that as it creates a lot of cooks in the kitchen. We know how challenging the beginning of FBT can be for the whole family, I think as clinicians we just support them. – Shelly Bar, MD
Agree with recommendation to hold off adding an individual therapist in Phase I. I haven’t seen that ever go well. I have a few cases now where the individual therapist was brought in Phase I. I’m constantly trying to uphold the power to the parents, because therapists want to find a way to give voice and choices to the child. – Katie Grubiak, RDN
Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.
It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.
What is Diet Culture?
Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.
Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.
Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.
Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.
We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.
Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
Teach your teen to think more critically about health and media messages they observe.
It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.
Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.
Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”
This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.
Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.
When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.
Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.
While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. There is one recent qualitative paper that studied the process of externalizing the eating disorder.
What are some advantages of externalizing the eating disorder?
It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
It puts everyone on the same team battling a common enemy: the eating disorder.
It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.
Reasons you might not want to externalize the eating disorder
Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.
According to the qualitative paper by Voswinkel and colleagues (2021), there were mixed perceptions about externalizing by patients interviewed. Some people with eating disorders feel like the eating disorder is a part of them and felt they were not taken seriously or criticized by externalization. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. People with eating disorders may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.
So, should you do It?
Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.
It is always a good idea to check with the person with the eating disorder about how they perceive externalizing. If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.
Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.
Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.
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 our low-cost eating disorder therapy program. Via our designation as a practicum site we are now able to train advanced graduate students in psychology in evidence-based treatment for eating disorders. This allows us to further our mission of helping to disseminate evidence-based treatments and to bring them to people in California who need them. We are also able to offer a true low-cost treatment option. Our psychology externs will be able to provide individual psychotherapy for adults with bulimia nervosa and binge eating disorder and teens and adults with disordered eating and body image concerns.
Beginning in August, 2021, the cost for sessions with our psychological externs is $60 per therapy hour. Sessions are available in-person in our office in mid-Wilshire area of Los Angeles and virtually with individuals throughout California.
As of June 2021, EDTLA has developed a memorandum of understanding with two local doctoral programs in clinical psychology— the California School of Professional Psychology at Alliant International University and Pepperdine University’s Clinical Psychology Doctoral Program of the Graduate School of Education and Psychology.
Each year, up to two advanced-level doctoral students are carefully selected through an interview process to be psychological externs at EDTLA. Psychological externs provide individual and group therapy to adults and adolescents.
All of the psychological externs receive extensive training through EDTLA’s training seminars and supervision program in order to provide quality therapy at lower fees than is typically found in Los Angeles.
All Psychological Externs work directly under Dr. Muhlheim (PSY15045), meaning that treatment decisions and progress are monitored on a weekly basis by an experienced licensed psychologist.
To inquire about receiving treatment from one of our psychology externs, please complete this form (and put Psychology Extern) under “Requested Clinician.”
You can read more about our current psychology externs here.
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 (Swenne et al., 2017). 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.
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.” For further guidance on parenting kids in larger bodies we recommend this guide to parenting fat kids.
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.