Participating on an FBT Team

Image by griffert from Pixabay

Family-based treatment (FBT) is the leading evidence-based treatment for teens with anorexia nervosa and bulimia nervosa. While in an ideal world, every person with an eating disorder would have access to a full treatment team including a therapist, a dietitian, a medical doctor, and a psychiatrist, FBT calls only for a therapist to guide the parents and a medical doctor to manage medical needs. A dietitian is not required, but I have found that a dietitian who works primarily with the parents can provide valuable guidance. Sometimes there are other treatment providers. If there are multiple providers, it is important that team members are in agreement about treatment philosophy and goals. Otherwise, a nonaligned team can potentially be detrimental.

Overview of FBT (3 phases)

Family-based treatment is a manualized therapy, presented in a “manual” with a series of prescribed goals and techniques to be used during each phase of treatment. It focuses on empowering the parents to play a central role in their child’s recovery, using contingencies to reverse malnutrition, increase weight, and eliminate symptoms including restrictive eating, bingeing, purging, and overexercise. FBT is based on five principles:

  • Agnostic view of illness—there is no need to find a cause or underlying issue that caused the illness.
  • Initial symptom focus—the focus is on reversing malnutrition and eliminating other eating disorder behaviors.
  • Family responsible for refeeding/addressing behaviors—parents are empowered to take charge of all meals—including planning, cooking, serving, and supervision—to ensure they are consumed as well as preventing other behaviors such as bingeing and purging.
  • Non-authoritarian stance—the therapist is a guide and partner that empowers parents to help their child.
  • Externalization of illness—the illness is seen as an external force that is threatening the child’s life.

FBT consists of three phases:

  • Phase 1: Parents are fully in charge of and supervise all meals until behaviors have largely ceased and weight is nearly restored.
  • Phase 2: Once behaviors are largely eliminated, weight is nearly fully restored, and meals are going smoothly, parents gradually hand back some control of eating to the adolescent in an age-appropriate manner.
  • Phase 3: Once the adolescent has resumed age-appropriate independence over their own eating, the focus of therapy turns to other adolescent development issues, any remaining comorbid problems, and relapse prevention.

When to Add Other Providers

Many parents are incredulous that family-based treatment is a standalone treatment. It is primarily a behavioral treatment focused initially on a brain rescue and then on eliminating symptoms. Medical providers unfamiliar with FBT and treatment centers that insist on having complete teams may pressure families to add an individual therapist for the patient with the eating disorder to the team. This is not always advisable. Sometimes, in FBT, less is more; the work of the parents can be undermined by an individual therapist who either does not believe in or support FBT. Additionally, research shows that at least in the case of bulimia nervosa, no additional therapy may be needed: issues with depression and self-esteem resolved during FBT treatment.

Family-Based Treatment Teams

Dietitians

For families that want to work with a dietician who is familiar with FBT, my colleague, Katie Grubiak, RDN, and I have worked out the following successful protocol. In Phase 1 of FBT, the dietitian is only included when needed and only meets with the parents. This helps to empower the parents and prevents the dietitian from inadvertently colluding with the eating disorder. When a dietitian meets the teen too soon, we have found that the eating disorder tries to ally with the dietitian and the teen spends the time trying to negotiate for preferred “eating disorder foods.” We find it more effective to avoid giving the eating disorder that voice. Parents—who have after all been feeding their child since birth—know what their teen truly likes and can avoid being manipulated by the eating disorder.

The situations in which I have found the dietitian to be necessary include the following:

  • The adolescent has another issue that necessitates dietary restriction such as celiac disease, diabetes, or a food allergy.
  • The teen’s eating has been extremely restrictive and the range of foods at the outset is extremely small
  • There is concern about medical issues such as refeeding syndrome and intake must be more closely measured
  • There is a history of an eating disorder in a parent and they feel insecure about challenging their child’s eating
  • The parents are highly anxious and unusually overwhelmed and benefit from greater support and direction from a dietitian.

Towards the end of Phase 2, I find it very valuable to have the dietitian begin meeting individually with the teen. This can be helpful in trying to increase the teen’s responsibility for their own recovery. The dietitian can also bridge the gap between the parents being in charge and the child being in charge by temporarily overseeing the child as the parents relax control. We have found it very beneficial for the dietitian to help the adolescent work on determining portion sizes and exposure to fear foods and eating in different contexts and to have some initial meals without the parent and see how they do.

Individual Therapists

Resources are limited: families have limited finances and there are not enough eating disorder providers to meet the demand of people with eating disorders. I believe that in most cases we should wait until Phase 2 of FBT before adding additional therapies. In this way, we can see what issues resolve on their own when weight is restored. After a teen has resumed regular eating and has nutrition sufficient to support higher level brain functioning, individual therapy can be added if it is needed. This is the point in therapy at which the adolescent is likely to be more receptive and able to benefit from individual therapy.

Having worked alongside several individual therapists providing individual therapy while I provided FBT, I have some suggestions that can help keep all providers on the same page and maximize benefits to the family. The most common scenarios I have encountered include the following:

  • Dialectical Behavior Therapy (DBT) therapist addressing emotion regulation
  • Exposure and Response Therapy (ERP) therapist addressing obsessive-compulsive disorder (OCD) or symptoms
  • Adolescent therapist addressing comorbid anxiety, depression, self-esteem, or interpersonal issues

The biggest problems I have encountered occur when individual therapists focus on coaching the adolescent to individuate and stand up to parents. This is inconsistent with the early stage of FBT, which requires the parents to be empowered to make all food decisions for an adolescent who is incapable of making reasonable decisions about food given their brain starvation. In FBT we don’t encourage independence in eating until the teen shows they can handle it. Similarly problematic are providers who educate the adolescent about his parents being too “enmeshed.”

On the other hand, I have had great experiences with individual therapists who understood that keeping the parents in charge of eating was crucial for the teen’s recovery. Instead, these therapists worked to empower the parents to help the teen eliminate other obsessive behaviors such as compulsive exercise. I have also worked with successful  DBT teams that focused on teaching the adolescent skills to manage her distress while not attempting to question or undermine the parents’ authority over food decisions.

Advice for The Individual Therapist

My advice for the individual therapist:

  • Don’t blame parents for causing ED
  • Don’t disempower the parents
    • Don’t question parents being in charge of food
    • Don’t suggest compromising on food choices
  • Don’t describe parents as enmeshed—instead, reinforce their instincts in attending to a very ill child
  • Don’t focus on empowering the adolescent to share frustrations about parents being in charge
  • Do focus on empowering the adolescent to demonstrate recovery behaviors even if it is for show (“acting as if”)
  • Help the adolescent to develop coping skills to use when the FBT process is upsetting to them
  • Respect parents’ choice to stop activities until they eat (delineate consequences before meals)
  • Help the adolescent fill their life with other things
  • Remind the adolescent that the parents will be able to give back control as the adolescent demonstrates readiness
  • Let the adolescent vent about their frustration over parents being in charge
  • Acknowledge that although there are many things the teen can do on their own that are developmentally appropriate, at the present time eating independently is not one of them

 

Nana’s Poundcake, Food, and Cultural Connection

Nana's PoundcakeFood for us comes from our relatives, whether they have wings or fins or roots. That is how we consider food. Food has a culture. It has a history. It has a story. It has relationships. –– Winona Laduke

Food is about more than sustenance. It is about pleasure and joy and connection. Food is one of the ways we connect with our cultural traditions and our ancestors. This is one of the reasons I am so passionate about my work to help people with eating disorders. When someone has an eating disorder and they are fearful of eating or of eating certain foods, they miss out on the pleasures of food and they miss out on the opportunities to connect with others through food. They also miss out on their own connection with their relatives and their cultural heritage.

In my own family, my 103-year-old Nana has always been known for her piano playing and her delicious poundcake. While her prized Steinway piano now stands in my home, I did not inherit her piano-playing her abilities. I did, however, learn her poundcake recipe.

From the time I was a young girl, I have memories of “Nana’s poundcake.” Simple to make with only 5 ingredients, buttery and yummy. During visits to Kansas City, I looked forward to making it with her. And when she visited us in New York we would make it together. And, occasionally my mom and I would make it without Nana. My kids have had the experience of making poundcake with my Nana, their great grandmother. And they have made it with me. After she eventually passes, we will retain this connection to my Nana and my kids will hopefully continue to make and share her recipe with future generations.

 

 

 

 

 

Photos of my daughters making poundcake with Nana back in 2012 at her apartment (she was 96)

I am glad to have this connection to Nana and to be able to fully enjoy making and eating poundcake with all its rich butter and sugar. What joy and connection I would be missing out on if I were afraid of eating it. To be able to make it and eat it with enjoyment enriches my life and allows me to have a shared experience through four generations of my family. I will always have joyful memories of baking and eating poundcake with the different generations in my family.

Bonus Feature — Nana’s Poundcake Recipe

  • 1/2 pound salted butter (2 sticks) – softened
  • 1 3/4 cup sugar
  • 5 eggs
  • 2 cups sifted flour
  • 2 T vanilla

 

  • Cream butter and sugar
  • Add eggs one at a time while beating constantly
  • Add flour and flavoring
  • Pour into well-greased loaf pan (or bundt pan)
  • Bake at 350° for 90 minutes

Photos from a poundcake I made with my daughter in 2019.

When Your Child With an Eating Disorder is Sick….

Guest post by Dr. Jennifer Johnson

When Your Child with An Eating Disorder is Sick...
Gambar oleh Clker-Free-Vector-Images pada Pixabay

When parents are renourishing a child with an eating disorder and that child gets sick, parents often don’t know what to do. Some families may back off on feeding every time a child gets any illness, which can be a risky practice. Especially during Phase 1 of FBT, ensuring eating is a priority. To help parents, I’ve asked Jennifer Johnson, MD, a medical doctor who specializes in treating patients with eating disorders, to share some advice.

First, let me say that in general, minor illness should not cause a kid with an eating disorder to lose weight. Parents who are refeeding their child know that even missing a meal or a snack makes a difference in their progress. Don’t let illness throw you off course. As you know, failure to gain as expected may occur if nutrition is even a bit compromised. It is absolutely not a given that illness or surgical procedure must cause weight loss. When I hear that someone has lost 3 pounds “because they had a cold” the previous week, I ask a lot of questions – that should not have happened.

Second, plan ahead. After you’ve read through my answers and looked at other parents’ recommendations, be proactive. Make a plan with your child and treatment team about what you will do if they get sick (which they inevitably WILL at some point during recovery). They should know that they WILL still be eating. But talk about what foods they tend to like when they are ill, and think about how to plug maximum nutrition into them. Buy any non-perishable supplies and stock up on over the counter medications for colds, coughs, and fever. (And please have a thermometer on hand! A $10 digital one is plenty good to give us doctors valuable information.)

What should parents do in terms of feeding when a child with an eating disorder has a head cold or sore throat and loses their appetite? Is it necessary to avoid dairy?

If your child is listless and feeling unwell, they will often not be very hungry for a couple of days. A sick child needs care and comfort. Caring for a sick child who has an eating disorder includes keeping up the nutritional intake. You don’t want the eating disorder to think that illness is a good way to sneak through the back door. And, there are other times when your child is not hungry, just from refeeding itself, and they have to eat anyway. So, push ahead, but gently. Present nutrition dense food and beverages that will be particularly appealing to your child. Does a milkshake sound appetizing? You can add a packet of Benecalorie. (There’s nothing wrong with dairy, by the way.) Chicken noodle soup? Maybe add some extra pasta. There are lots of helpful posts from parents on the Around the Dinner Table Parent Forum.

What about if they have a fever?

Having a significant fever (101 or above) increases fluid needs as well as metabolic rate (more calories are burned). Your child will feel better if you control the fever with regular doses of acetaminophen or ibuprofen. Giving the medication at regular intervals, say every 6 hours for acetaminophen, may prevent the fever from getting as high as it otherwise might. This also helps with the headaches that usually accompany fever. Keeping your child hydrated, particularly with something like Gatorade, will also help them feel better – and thus more likely to have some appetite. Some kids maintain their appetite when they have a fever and of course, it’s fine to continue refeeding. Otherwise, know that keeping up nutrition during an illness helps your child feel better sooner, and push on. Again, it’s helpful to adjust what you give them based on their preferences.

What about when kids in recovery have the stomach flu?

What do you do if they’re vomiting?

Generally, vomiting is worst at the onset of an episode of stomach flu and becomes less frequent over the next 24 hours. A parent’s main goal when a kid is vomiting is to keep them hydrated. I recommend not giving anything by mouth for 2 hours after they’ve thrown up. Then you can give them ice chips or a couple of teaspoons of water. This liquid will get absorbed from the mouth. Do this every 5 minutes or so for half an hour. If they haven’t vomited again, you can have them try slightly larger amounts of liquids at less frequent intervals. They should be able to keep down about 2/3 of a cup of liquid, and be hungry, before you try a very small amount of food. Slowly increase the amount you give them. Kids may become ravenous and eat a huge meal, but then throw up everything they’ve just eaten. A kid who throws up a day or two into recuperation may have just overdone it. In that case, you’ll need to let up a bit before pushing back into refeeding.

What about diarrhea?

For kids with diarrhea, we don’t generally recommend giving any medications that are designed to decrease the number of stools (bowel movements). No major food restrictions are needed. There is nothing magical or beneficial about the so-called BRAT diet (bananas, rice, applesauce, toast), which is of low nutritional density. Studies have shown that having diarrhea for a few days does not make someone lactose intolerant. We know that eating when you have a “stomach bug” with diarrhea will generally increase the number of diarrheal stools. But we also know that at the end of the illness, people who have continued to eat will end up better nourished (= digested more calories). And that, of course, is the ultimate goal.

One thought: you may want to speak with your child’s doctor about a proactive prescription for a small number of anti-emetic tablets (that dissolve in the mouth) to have on hand in case your child gets stomach flu. I don’t normally recommend this but refeeding is an exception. We want to minimize the duration of nausea and vomiting to make it easier for your child to eat. Also, many of my patients who have eating disorders are afraid of truly fearful of vomiting (a condition called emetophobia), which only makes stomach flu worse for everyone. If your doctor is willing to do this, they undoubtedly want you to call before you give the medication.

What if your child has no appetite (due to illness)

Biology is on our side. When a kid (or another human being) eats less due to a minor illness, appetite typically returns with a vengeance and we make up for what we’ve missed. For a kid in the early refeeding phase, of course, it is normal to not feel hungry. So you may not know whether your child is not hungry because they’re not feeling well or because they’re refeeding. In either case, your eating disordered child needs you to continue to push forward. Refeeding is the mainstay of treatment and you’re the team leader. Go for it!

Please note that none of the above should be construed as medical advice. If you have concerns about your child’s health, contact their doctor. Some examples of when you should call the doctor are: Bloody diarrhea, high fever (102 or above), vomiting that continues more than 24 hours, weakness, severe dizziness or fainting, or very little urine.

About Jennifer Johnson, M.D., MS, FAAP

Dr. Johnson is a medical doctor. She has more than 20 years’ experience as a pediatrician and adolescent medicine specialist. She practices in Newport Beach (Orange County), California.

Dr. Johnson is certified by the American Board of Pediatrics in Adolescent Medicine as well as in Pediatrics. Dr. Johnson also has an advanced degree in public health. She has been a professor in the Department of Pediatrics at the University of California, Irvine School of Medicine, where she served as director of the adolescent medicine program. Dr. Johnson has taught medical students, residents, faculty, and community physicians, for whom she continues to present educational programs. She has presented at national meetings of many organizations, including the American Academy of Pediatrics and the American Academy of Family Practice. Dr. Johnson has written many research articles and book chapters related to adolescent and young adult medicine.

Dr. Johnson is an advocate for adolescents and young adults. She is a Fellow of the American Academy of Pediatrics (AAP). She has led many activities in the Academy’s Section on Adolescent Health and served as its chairperson. Dr. Johnson is active in the Orange County chapter of the AAP, as well. Current projects include the Teen Safe Driving Initiative and healthcare for GLBTQ teens.

Dr. Johnson has also been active in the Society for Adolescent Medicine. As a member of the medical advisory board for Teengrowth, Dr. Johnson wrote many articles and answers to reader questions. Articles and webcasts by Dr. Johnson are posted at Healthology.com, medbroadcast.com, and the New York Daily News. 

Dr. Johnson is on the medical staff of Hoag Hospital in Newport Beach.

Parent Volunteers Needed for Eating Disorder Recovery Research Study

Parent Survey Eating Disorder

 

Mayo Clinic researchers are conducting a study examining parents’ perspectives on eating disorder recovery. We believe that parents have valuable information about their children that can help us better understand eating disorder recovery and improve treatment outcomes. If you are a parent of a child or a teen with an active or past eating disorder, we would appreciate your input by taking an online survey. If you are interested in participating, please click on this link:

Parent Survey of Recovery

You may share this message and link with anyone else or any group that you think might be interested in participating.

This survey is for parents who:

  • Have a child or a teen who was diagnosed with an eating disorder before the age of 18
  • Have access to some data about their child’s heights and weights prior to diagnosis, at diagnosis, and after diagnosis (any measurement system is fine!)

We will be asking you questions about your child’s illness and aspects of recovery, including weights and heights if you have them. If you have growth records, it would be helpful to gather them before taking the online survey. The survey should take about 30 minutes to complete and will be anonymous.

Study Information

Understanding Carers’ Experience in Treatment for Their Child’s Eating Disorder

Principal Investigator: Jocelyn Lebow, Ph.D.

Additional Investigators: Erin Accurso, Ph.D., Leslie Sim, Ph.D., and Lauren Muhlheim, Psy.D.

You are being asked to participate in a research study to understand carers’ experience in treatment for your child’s eating disorder. This invitation is being posted on blogs, social media groups and sent to listservs for parents of children or adolescents who have had/ currently suffer from an eating disorder.  If you agree to participate, you will be asked to spend approximately 30 minutes completing an online survey. We will ask you questions about your experiences during your child’s treatment and your personal definition of “recovery” for your child. The survey is anonymous, so your answers cannot be identified or traced back to you.  The risks and burden associated with this research study are minimal. While there is no direct benefit to you if you choose to take this survey, we believe that this research study will provide a better understanding of carers’ perspectives of their children’s treatment and recovery, with the goal of improving treatment and outcome assessment.  Please understand that this is a voluntary study and your current and future medical care at Mayo Clinic will not be affected by whether or not you participate. Contact the Mayo Clinic Institutional Review Board (IRB) to speak to someone independent of the research team at 507-266-4000 or toll-free at 866-273-4681 if you have questions about rights of a research participant. Thank you for sharing your time and expertise.

 

The researchers

Sweatin’ for the Wedding: Say, “I don’t.”

Sweating for the Wedding? Say: I Don’t.
Image by rawpixel on Pixabay

by Carolyn Hersh, LMFT

In November of 2018, my boyfriend proposed to me. It was one of the most exciting days of my life thus far. With a proposal comes the next exciting chapter: wedding planning. For many brides-to-be, this entails finding that perfect gown.

Sadly, although not surprising, once I got on bridal mailing lists, I learned I was also being targeted by gyms for “Bridal Boot Camps” and “Sweatin’ for the Wedding.” The weight loss industry found yet another way to weasel their way into a life event that should have nothing to do with changing one’s body.

Why is it that you could be with someone who you love for a certain amount of years, and suddenly the moment they place a ring on your finger you need to change your body? Why does looking beautiful equate to weighing less?

Unfortunately, it has become the norm in our culture to experience pressure to lose weight for special events. A friend once shared that when she was dress shopping her consultant actually wrote down smaller measurements because “all brides lose weight.” When my dress consultant mentioned letting her know if I lose weight, my initial thoughts were, “Are you telling me I need to lose weight? Am I supposed to lose weight? What if I like my body where it is? What if I want to gain weight?”

Granted, our bodies can change. But, hearing about weight loss, exercise programs, and diets specific for the big day can be detrimental to our physical and mental health. The diet industry has found another market and doesn’t care how it impacts the people getting married.. Wedding planning can be stressful enough with trying to create a special day without the added pressure to create a “perfect” body.

But, here is the thing. Your fiance asked to marry you not because of what you’ll look like on that one specific day, but because they are in love with you and everything about you. Getting married is about making a commitment of love to one another. Your wedding day should be a celebration of that.

As brides or grooms, we should dress up and present ourselves the way we want to on this day but, it should not be at the expense of our health and well being. Remember what this day is about. Your wedding is not about the celebration of the size of your body but about the love between you and your significant other and making a commitment to one another.

What to do Instead of “Sweatin it”

Here are some tips I have developed to use myself and also with my clients who were wedding dress shopping:

  1. Buy a dress that fits you now. Don’t buy something a size smaller. Don’t use words like “my goal size” or “I’ll be pretty when I fit into this.” Fighting your body to go to a size it isn’t meant to be is only going to add more frustration, stress, and sadness. If the person selling you a dress keeps harping on “when you’ll lose weight” or “all brides lose weight” speak up and tell her that isn’t your plan. You do not have to be a victim of diet culture. Buy the dress that makes you feel pretty right now. Also, do not forget that many dresses you try on are just sample dresses. It’s okay if it doesn’t fit perfectly when you try the dress on. The one you get will be tailored to your already beautiful body,
  2. With that, remind yourself of the things that not only make you look beautiful but what makes you feel beautiful. One of my bridal consultants asked me when picking out a dress, “Do you want to feel whimsical? Do you want to feel like a princess? Do you want to be sexy vixen?” Wedding dress shopping became ten times more fun when I could close my eyes and imagine what style of dress would make me feel the most beautiful.
  3. Write down what you want to feel on your wedding day. Write down your hopes and excitements for this day. Think about what memories you want to hold onto.  While the idea of “looking perfect” in your wedding photos may be a strong drive to engage in diet culture, think about what those photos are truly capturing. Most likely, you’ll want to remember this as a day of celebrating love and new beginnings with your partner.
  4. It’s okay to exercise and it is okay to eat. It’s okay to follow your normal routine, As you plan for your wedding continue to follow your intuitive voice. For many people, weddings take months if not years to plan. Do not remove fun foods out of your diet for the sake of just one day. Listen to your body when it comes to exercise. Exercise because you want to give your body the gift of movement, but know it is okay to take days off too. Exercise should not be a punishment to your body.

In Conclusion

You do not need to lose weight for your wedding day. Ultimately, remember what this day means to you and your partner. Your wedding dress should be the accessory to the already amazing you. You know, the person that your partner wants to spend the rest of his or her life with. So, when it comes to “sweatin’ for the wedding,” say, “I don’t.”

Breaking The Myth: Men and Eating Disorders

Male Eating Disorders
Photo by Fares Hamouche on Unsplash

by Carolyn Hersh, LCSW

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

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

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

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

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

Eating disorders in males may look different.

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

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

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

Source

National Eating Disorder Association

Recovery When Grieving by Carolyn Hersh, LCSW

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

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

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

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

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

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

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

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

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

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

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

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

Curate Your Feed with Diverse Body Positive Accounts on Instagram

Photo, Resilient Fat Goddess Instagram

by Sarah Thompson, Resilient Fat Goddess and Lauren Muhlheim, Eating Disorder Therapy LA

“Body positivity can’t be just about thin, straight, cisgendered, white women who became comfortable with an additional ten pounds on their frame.” —Stacey Rosenfeld, Ph.D., Shape magazine (July, 2018).

Eating disorders are about so much more than body image, but the current diet culture, idealization of the thin ideal, and “war on obesity” make it much harder for people with eating disorders to recover. We are barraged on a daily basis by media images of people who represent only a small portion of the population.

As Dr. Muhlheim discussed in a previous post about fat photography, 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.

Thus, an important exercise for people of all sizes in recovery is to curate their social media feed by removing accounts that perpetuate the thin ideal and expand the range of body sizes and types to which one is exposed. Adding diversity to your social media feed isn’t only important for people in recovery, it can be just as important for partners as Sarah Thompson wrote about here. It would even be useful for parents and family members of those recovering.

The term used to describe the absence of representation in media was coined by George Gerbner in 1972. This phenomenon is “symbolic annihilation.” Gerbner was a Hungarian Jewish immigrant and communications professor who researched the influence of television trends on viewers’ perceptions of the world. According to Coleman and Yochim, Gerbner explained that “representation in the fictional world signifies social existence; absence means symbolic annihilation.” Representations, or lack thereof, lead to assumptions about how the world works and who holds power.

Gerbner did not assign symbolic annihilation to any particular group, so it has since been applied to many different identities. We can apply the concept to non-dominant systemic identities, such as larger bodied people, people of color, trans and gender-expansive people, disabled people, etc. If we don’t see bodies like our own represented, we may come to believe “my body doesn’t matter”. Often, this can turn into “I don’t matter”. This means that for people whose bodies are marginalized in any way, it is essential to see images of people that look like them.

We have developed a roundup of Instagram accounts to help you on the journey. While it is not comprehensive, it is a starting point. What follows are some Instagram accounts that show body-positive images that celebrate diverse bodies in ways that mainstream media does not.

At the time of this posting, these accounts are free of body shaming, fat shaming, food shaming, and disordered eating. Some are people in recovery from eating disorders. If we missed one of your favorite accounts that consistently publishes photos of bodies at the margins, please email us and let us know!

Larger-bodied women

@madeonagenerousplan

@iamdaniadriana

@themilitantbaker

@fatgirlflow

@fatwomenofcolor

@cosmiccollette

@bampowlife

@danielle_bex

@fatlippodcast

@shesallfatpod

Larger-bodied men

@bigboysarecute

@johnasavoia

@abearnamedtroy

@chubstr

@bear_skn

@zachmiko

@300poundsandrunning

People of color

@iamivyfelicia

@onebeautifulyes

@thefriendineverwanted

@nalgonapositivitypride

@sonyareneetaylor

@virgietovar

@genizeribeiro

@ihartericka

@diannebondyyoga

@mynameisjessamyn

@biggalyoga

@sassy_latte

@adydelvalle_

@melissadtoler

Gender diverse people

@transfolxfightingeds

@comfyfattravels

@chairbreaker

@thirdwheeled

@alokvmenon

@nonnormativebodyclub

@shooglet

@resilientfatgoddess

@thefatsextherapist

@watchshayslay

Older people

@efftheiragingstandards

@idaho_amy

@lamplight.space

@gidget3304

@glitterglama

@fruitbat5150

@26kleisen

@finally_bopo

People with disabilities

@the_feeding_of_the_fox

@dietitiananna

@theonearmedwonder

@rollettes_la

@disabilityisdiversity

@the_hapless_roller

@spookyfatbabe

@disabled_fashion

@princesscakep0p

@everybodyisworthy

Multiple Identities

@thebodyisnotanapology

@decolonizingfitness

@subversesirens

@fatkiddanceparty

@adipositivity

@underneath_we_are_women

@lkt_consulting

@flourorchalk

Other body positive accounts to follow

@sweetamaranth

@iamannachapman

@nolatrees

@bopolena

@bopo_watercolour

@shoogsart

@shelby.bergen

@neoqlassicalart

@lovefromdanica

@bopo.boy

Source

Coleman and Yochim. The Symbolic Annihilation of Race: A Review of the “Blackness” Literature. Perspectives. Spring 2008. http://www.rcgd.isr.umich.edu/prba/perspectives/spring%202008/Means%20Coleman-Yochim.pdf

August 2018 LACPA Eating Disorder SIG Event

Jaye Azoff, Psy.D., Los AngelesDate: Wednesday, August 22nd at 7:30 pm

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

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

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

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

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

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

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

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

RSVP to:  drmuhlheim@gmail.com

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