Categories
ARFID

How Diet Culture Can Harm Your Recovery from ARFID

by Carolyn Comas, LCSW, CEDS-S

People diagnosed with Avoidant Restrictive Food Intake Disorder (ARFID) struggle with consuming adequate nutritional intake due to either 1) fear of aversive consequences (i.e choking), 2) low interest in food altogether, or 3) sensory sensitivity to food textures, smells, or appearance. Usually, people with ARFID do not report refraining from eating due to fears of weight gain or efforts to lose weight. In fact, many people with ARFID welcome weight gain and want to expand their food variety.   

The Impact of Diet Culture

The current Diagnostic and Statistical Manual (DSM-5) excludes those whose eating is restrictive due to shape and weight concerns from receiving a diagnosis of ARFID. However, this does not mean that people with ARFID are immune to the societal messages around food and bodies. Sadly, we all live in a world that is very much driven by diet culture. Most of us, with or without eating disorders, can be impacted by diet culture. We are constantly bombarded by many sources, ranging from the media to doctors’ messages about the danger of fatness and categorizing foods as healthy or unhealthy. 

Dieting is one of the leading causes of eating disorders. According to a study by the National Eating Disorder Association, 35 percent of people who diet progress into pathological dieters. Of this 35 percent, up to 25 percent will develop a full-blown eating disorder. People with ARFID could develop another eating disorder, such as bulimia nervosa or anorexia nervosa at some point in their life.

People with ARFID already face the challenge of limited food choices and heightened anxiety around eating. They can be very vulnerable to messages that their preferred foods  “aren’t healthy” or “junk food.”  This can lead to even more anxiety and shame around their food choices. People with ARFID thus have to battle their disorder as well as the concerns that diet culture imposes around food and body size.

Dieting encourages us to ignore our bodies’ needs. Diet culture emphasizes that our worth is based on the size of our bodies. In Christy Harrison’s book, Anti-Diet, she calls it “the life thief.” And that’s what it does- it steals the joy out of fun events or the everyday activity because it convinces us we need to carefully balance everything we put in our body. And if we go off the diet or “cheat” we are made to feel bad and unworthy causing a vicious cycle of yo-yo dieting. 

People with ARFID with whom we have worked report confusion around some of these messages, which clearly come from diet culture, and affected their ability to eat their preferred foods:

  • “Water is the only hydrating beverage and I should only be consuming water.”
  • “I was only offered wheat bread which I didn’t like so I didn’t eat bread.”
  • “I must eat vegetables in order to be healthy.”
  • “Fried foods are bad so I should limit my chicken nuggets and french fries.”

Standing up to Diet Culture

If you have a loved one struggling with ARFID it is recommended to check your own relationship with food and body image. Explore your own internalized fat phobia. Great books include The Body is Not an Apology by Sonja Renee Taylor and What We Don’t Talk About When We Talk About Fat by Aubrey Gordon. If you are worried about the types of food you or your child is eating because it is “unhealthy” check in on what you are really worried about. Is it truly about the nutritional value of the food or is there a belief that these particular foods can lead to being in a larger body? If the fear is being in a larger body then you have work to do. Learn about Health at Every Size® and recognize that the size of our bodies does not correlate to how healthy or unhealthy we are.

Remember, it is better to be fed than to be dead. If all you or your child can eat is chicken nuggets or french fries or potato chips or white bread (or all 4), then that’s what needs to show up at each meal and snack. You or they should have permission to eat preferred foods at every meal and snack without shame. With therapy, the goal is to incorporate more food groups and decrease fear and anxiety around novel foods. Realistically people who struggle with ARFID might never have the most expansive palette and that’s okay. If protein has to come from a package or be fried then that’s where the protein has to come from. Insisting that one food is better than another can make a person with ARFID feel ashamed, embarrassed, or more anxious about their food choices and further limit their eating. We never want to limit the food choices of people with ARFID beyond those limitations that the disorder causes. Choosing to feed yourself foods our culture considers “less healthy” rather than not eating is the best and dare I say–-healthiest choice there is.

When it comes to expanding variety and trying new foods we always have to start with what feels safe for the person with ARFID. While the goal might be to eat blueberries the first step might be eating blueberry muffins or chocolate-covered blueberries. The goals of treatment are to make meals less intimidating and have the patient feel like they can master trying new things. We don’t want to increase shame by disparaging their food choices.

We need to create peace, joy, and relaxation around meals. Labeling food “good” or “bad” or “healthy” or “unhealthy” can increase anxiety and discomfort.  Patients may second guess their food choices or end up becoming even more limited in what they eat. A fat-phobic mindset can be intimidating. Taking a Health at Every Size ® approach will be as important as it is in the treatment of anorexia and bulimia. It is the safest approach to navigating the world of diet culture. 

Let’s push back on diet culture and spread the message that all bodies are good bodies regardless of their size. We need to make the world safe for people in fat bodies and for those in thin bodies who are fearful of becoming fat. Ultimately, diet culture is not only harmful to people with other eating disorders but is also harmful to those with ARFID.

Groups at EDTLA

We have groups for adults with ARFID as well as parents of teens with ARFID. For more information, check our Groups page.

Categories
body image Group therapy

Eating and Body Image Therapy Group for Men

We are excited to announce our Eating and Body Image Therapy Group for men beginning in September 2022 over Zoom.

This group is for men who are looking for a supportive space to discuss issues around body and eating and/or are looking to add group therapy to their eating disorder recovery. If you are tired of pursuing thinness/fitness, have struggled with disordered eating, and are interested in divesting from diet culture, this group is for you. Through connection, we will explore diet culture and the pressures on males to have a perfect body. We will work to heal your relationship with your body and will learn about non-diet approaches to health.

While eating disorders are often commonly believed to almost primarily affect females, eating disorders have been recognized as affecting males too–and as far back as 1689 when one of the first noted cases was of a male patient. Approximately 25% of the individuals with anorexia nervosa and bulimia nervosa are male. We recognize that males with eating disorders have different experiences and need their own space. Males with eating disorders may experience different symptoms including greater muscularity concerns and have a greater risk of suicidality. They may experience stigma for being seen to have what is commonly believed to be a female disorder and often are not diagnosed until later in their illness.

Group Details

The group will meet weekly on Wednesday evenings at 6 pm over Zoom and is open to anyone ages 18 and up who identifies as male and is located in the state of California. This group is for you if you are looking for a supportive environment to discuss issues surrounding body image and eating and what it is like to be male in our culture.

Register

The group is led by Jonathan Dang, LMFT, who is passionate about supporting males with eating and body issues. Jonathan is currently pursuing certification as an eating disorder specialist. To register email Hello@EDTLA.com and put “Male Group” in the subject line.

 

Categories
College Mental Health Eating Disorders Family based treatment

Eating Disorder College Contracts

If you are sending a young adult with a history of an eating disorder to college (or seminary or another away program), it is a good idea to have a college contract in place. This is our recommendation for young adults with anorexia, bulimia, binge eating disorder, ARFID, and OSFED.

College and living away from home for the first time brings novel stressors and recovery challenges. Any transition can challenge the most stable of recoveries. The freedom and independence can provide a breeding ground for an eating disorder. Your young adult will be eating in an entirely different context than the one they have practiced recovery in. Relapses during college or the first period of independence are not uncommon.

Prior to sending your young adult with an eating disorder off to college or a similar independent experience you will want to ensure that your young adult is ready for the challenge of being away from home. A contract is NOT a substitute for readiness. Read more about our criteria for readiness in our post about college readiness. If you deem them ready, a college contract can be very helpful.

A contract is an agreement between the parents and the student—obviously not a legally binding document. Treatment professionals may help develop the contract or play a role in supporting the contract, but they are not parties thereto. I think about a contract as a safety net rather than something adversarial. Parents are on the side of their young adult—and are merely saying, “We want you to be in college, but we want to ensure that you are healthy enough to stay there in order to fully benefit from the college experience.” They then use the contract to specify the criteria required for the student to stay in college, as well as the consequences if those criteria are not met.

As long as you are paying for some of your young adult’s school or living expenses, you have leverage and can require a contract. I do not advise counting on the school to ensure your young adult stays well. No college, even those with excellent mental and physical health resources, is able to provide the level of oversight that parents do.

A contract should include the following:

  • A minimum healthy weight for your student based on optimal physical and psychological recovery and historic weight patterns, ideally developed with a treatment team and taking into account that young people are expected to gain weight until about age 20
  • A release of information signed by your student, allowing treatment professionals to communicate with you
  • A plan and cadence for your student to get weighed and have their vitals checked
    • Some families are able to set this up with the college health center; others with private practice professionals (MD, RDN, or therapist)
    • The frequency of weighings and vitals will be determined based on length in recovery and stability
  • A plan for consistent communication of the above weights and vitals information (i.e., each time it’s checked, or only if concerning; to whom on the team and when to parents).
  • Recommended treatment follow-up with various professionals. This ideally follows the recommendation of the prior treatment team and may include as many team members as necessary. Some individuals may need a full team; others may just need weights and vitals.
  • An expectation regarding behaviors:
    • Meals—how many meals and snacks the student is expected to have and any associated guidelines, such as a meal plan.
    • Exercise—any appropriate restrictions.
    • Any other behaviors of concern, such as purging
  • The specific steps parents will take if there is a lapse including weight loss or an increase in eating disorder behaviors.
    • For smaller lapses, parents may give the young adult some time to self-correct or regain weight independently and maybe increase sessions with team members before initiating other steps.
    • Some parents specify that they will come to school and stay with the student and try to help them for a time to get on track while staying in school.
    • If these steps are not working and for more significant lapses, parents may require the student to come live at home or go to residential treatment.

As with any consequence, parents should not include anything in the contract on which they are unwilling or unable to follow through.

I recommend that parents and their students start talking about the college contract and college readiness at least six months before the start of college, so the young adult is not surprised by the idea of a contract. I suggest parents write the first draft and then share it with their treatment team and their young adults and then incorporate feedback. The agreement should be signed by the parents and the student and the current treatment team members may also sign it showing their endorsement.

Sample College Contract:

In order for Mary to be successful at college, we agree to all the terms set out in this agreement and will not take action beyond what is prescribed in the agreement without a review with Mary and her team first.

  • We will treat Mary like a responsible adult.
  • We will not show up at college unannounced.
  • We will give 24 hours’ notice before visiting.

In order to remain at college:

  • Mary will be weighed weekly at her counseling sessions with Dr. Freud. Dr. Freud will communicate her weight to her parents each week.
  • Mary will attend weekly counseling sessions with Dr. Freud and bi-weekly appointments with dietitian Nancy.
  • Mary will eat 3 meals in the dining hall and 3 snacks daily containing appropriate amounts of fats, carbs, and protein in order to maintain her weight. She will eat a dessert daily.
  • Mary will not become a vegetarian.
  • Mary will maintain a minimum weight of 140 pounds.
  • If Mary binges/purges, she will discuss it with Dr. Freud and Nancy and develop a plan.
  • Mary agrees that physical and emotional health and safety are a higher priority than educational progress or participation.
  • Mary will be mindful of exercise as a potential trigger and will limit exercise to no more than 3 times a week for 30 minutes. Mary agrees she needs to consume sufficient food to fuel her level of exercise.

The following backup plan is not a punishment but a safety net to facilitate ongoing progress:

  • If Mary’s weight drops below 140 pounds, she has 2 weeks to regain the lost weight. Her parents and dietitian will help with suggestions and provide more snacks.
  • If lost weight is not regained by the 2-week mark, one of her parents will come to college at the end of classes for the week and all meals and snacks will be supervised by her parents for the weekend, even if Mary has to cancel something. Mary can return to classes after the weekend after the Sunday evening snack. Supervised weekends will continue until weight is back above 140 pounds. Once the weight is regained, Mary can remain at school without parental supervision.
  • If supervised weekends do not result in expected weight regain in 2 weeks, Mary will return home until weight is regained.
  • If Mary fails to comply with any of this agreement, she will need to withdraw and either enter residential treatment or seek employment.

We will review this contract at the beginning of each academic semester and revise it as needed to help Mary maintain healthy eating habits.

Signed:______________________                Date:_______________

 

Signed:______________________                Date: _______________

 

 

Witness: ­­­­­­­­­­­­_______________________           Date:­­­­­­­­­­­­­­_______________

Categories
Health at Every Size

How a Health at Every Size(R) (HAES) Approach Can Help With Eating Disorder Recovery

Body Liberation Photography
Eating disorders are not only about body image. Nor have they only recently arisen in response to societal pressures to be thin. In fact, eating disorders date back to at least the 13th and 14th centuries, when it was documented that women were fasting to demonstrate religious devotion. However, today eating disorders do occur in the context of a society obsessed with thinness, afraid of fatness, and permeated with diet culture. This makes recovery more difficult.

How Diet Culture Impacts Eating Disorders

There are probably no other mental disorders whose behaviors the culture admires and values as greatly as the eating disorders. People frequently praise people with restrictive eating disorders for their self-control and success at dieting or commitment to exercise. Imagine being praised for the symptoms of other disorders, such as excessive worry or the inability to get out of bed due to depression. When it becomes “normal” for everyday discussions to revolve around diet suggestions or the shame of eating tasty food, recovery becomes even harder.

Research on Weight Stigma

The focus on eradicating “obesity” leads to discrimination and stigmatization of people living in larger bodies. In turn, this stigma encourages numerous negative psychological and health consequences. Studies have shown that weight stigma increases unhealthy eating behaviors— including binge eating—and decreases participation in physical activity. Weight stigma also has been shown to lead to depression, stress, low self-esteem, and negative body image. In fact, many of the negative health consequences commonly attributed to greater weight are now believed to be exacerbated by weight stigma itself.

Research on Weight Loss

Most individuals are unable to maintain weight loss long-term. Only 3% of dieters maintained weight loss at 5 years according to one study (Anderson et al, 2001). Mann and colleagues (2007) found that one-third to two-thirds of dieters regained more weight than they initially lost on their diets and concluded there was “little support for the notion that diets lead to lasting weight loss or health benefits.”
Diet failure can also lead to weight cycling: alternating periods of weight loss and weight gain. Weight cycling has been shown to lead to psychological and health problems. In addition, it can lead to reduced metabolic energy expenditure, which makes regain more likely.

What is Health at Every Size®?

Health at Every Size® (HAES) is an approach to health that shifts the focus from weight to health. It is a philosophy that has emerged primarily since the late 1990s. It is promoted by the Association for Size Diversity and Health (ASDAH), which owns the phrase as a registered trademark.

The primary goal of HAES® is to promote healthy behaviors for people of all sizes. HAES® is grounded in five principles:

  • Weight Inclusivity: acceptance that bodies naturally come in a variety of shapes and sizes, and no size of body is inherently better than any other size of body.
  • Health Enhancement: the focus on health rather than weight and attendance to additional disparities that contribute to health including economic, social, spiritual, emotional, and physical factors.
  • Respectful Care: acknowledgment of weight bias and weight-based discrimination, and the commitment to work towards its end. This involves the adoption of an intersectional lens to understand different identities such as race, body size, gender, sexual identity, etc.
  • Eating for Well-Being: flexible, individualized eating based on hunger, satiety, nutritional needs, and pleasure—not external eating guidelines focused on weight control.
  • Life-Enhancing Movement: encouragement of enjoyable physical activities for people in a range of bodies with a range of abilities, to the extent that they wish to participate.

What Research is there in support of HAES®?

Several studies support the use of HAES® interventions. Individuals who received HAES®-based interventions had improvements in physiological, behavioral, and psychological measures. Subjects exhibited statistically and clinically-relevant improvements in blood pressure and blood cholesterol levels. They displayed increased physical activity and decreased eating disorder symptoms. Subjects also had increased self-esteem and body image and decreased anxiety and depression. They exhibited increased fruit and vegetable intake. No studies found any negative consequences associated with the HAES® interventions. Subjects who receive HAES® interventions seem to stay in their programs longer. This is promising, considering that patients in weight loss programs often drop out.

How Can a HAES® Approach Help With Eating Disorder Recovery?

Weight recovery is a prerequisite for recovery from anorexia nervosa. Aside from the necessity of restoring suppressed weight for individuals with eating disorders who are weight suppressed, the treatment of eating disorders should not aim to address weight issues. Weight loss has not proven effective for patients with binge eating disorder. There is growing evidence that individuals who try to lose weight and maintain a suppressed weight—that is, a weight lower than a previous higher weight—are at increased risk for binge eating disorder and bulimia nervosa. Individuals with bulimia nervosa who maintain a suppressed weight are less likely to fully recover. A persistent focus on limiting weight gain or losing weight can drive and maintain eating disorder behaviors. Research shows that continued focus on weight loss as a goal can lead to food and body preoccupation, eating disorders, weight stigma, and reduced self-esteem.
Conventional thinking suggests that feeling bad about one’s body would motivate behavioral changes that promote weight loss; in fact, the opposite is true. Feeling bad about one’s body drives more destructive behaviors. By contrast, body acceptance can help promote healthier behaviors.

Renouncing the dieting mindset and returning forbidden foods back into their diet can be a formidable challenge for patients surrounded by friends and family who talk about losing weight or avoiding certain foods. Adopting a HAES mindset can challenge the veneration of thinner bodies and promote body acceptance.

The HAES® approach shifts the focus from the resolution of weight issues to the resolution of body discontent. It encourages you to accept your body’s “set point”: the weight to which your body tends to return when you don’t fixate on weight loss and instead respond to your body’s natural cues for hunger and fullness; the weight you to which you return between diets; and the weight you maintain without a lot of effort. This is the weight your body “wants to be.”

While a HAES® approach acknowledges a correlation between higher weights and certain medical conditions, it questions whether this relationship is purely causal. The data suggest that behavior change may play a greater role in health improvement than weight loss itself. We know that weight loss rarely works, and when it does, people lose only a modest amount of weight and maintain even less of it. Is weight loss just an occasional and incidental result of the health improvements driven by these behaviors, rather than an important end in itself?

Each body is different. Humans naturally come in all varieties of shapes and sizes. It can be hard to remember this in a world where the dolls with which our children play are all white and svelte and the protagonists in television and movies are also in conventionally attractive bodies. The shape and size of our bodies are largely determined by genetics, just as is the color of our eyes and skin. A HAES® approach allows you to trust your body to maintain the body size and shape that is right for YOU.

The HAES® approach advocates for intuitive eating—listening to and acting on internal hunger and satiety cues and preferences. Those in recovery who have previously allowed proscriptive external diet rules to drive their food decisions may be especially helped by the HAES approach. HAES also recommends pleasurable movement—exercising for the goal of pleasure rather than weight loss. Decoupling exercise from weight loss is challenging for many patients with eating disorders.

We can work with people in person in Los Angeles and virtually throughout the state of California seeking HAES-informed treatment.

How Can I Learn About HAES?

There are many ways to learn more about HAES. Check out the following resources.

Websites

Video:

  • The Problem With Poodle Science by The Association for Size Diversity and Health is an animated video exposing the limitations of current research on weight and health

Books:

  • Health at Every Size: The Surprising Truth About Your Weight, by Linda Bacon, PhD addresses weight myths and gives the science behind HAES.
  • Body Respect: What Conventional Health Books Leave Out, Get Wrong, or Just Plain Fail to Understand about Weight, by Linda Bacon, PhD, and Lucy Aphramor, PhD, RD includes the latest science on diets and health and why diets fail. It teaches how to adopt a HAES approach.

There are also many blogs and social media groups and accounts focused on Health at Every Size. Try searching for #HAES.

Sources

Anderson, J. W., Konz, E. C., Frederich, R. C., & Wood, C. L. (2001). Long-term weight-loss maintenance: a meta-analysis of US studies. Am J Clin Nutr, 74(5), 579-584.

Bacon, Linda, and Lucy Aphramor. 2011. “Weight Science: Evaluating the Evidence for a Paradigm Shift.” Nutrition Journal 10 (January): 9.

Mann, T., Tomiyama, A. J., Westling, E., Lew, A.-M., Samuels, B., & Chatman, J. (2007). Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol, 62(3), 220-233.

Penney, Tarra L., and Sara F. L. Kirk. 2015. “The Health at Every Size Paradigm and Obesity: Missing Empirical Evidence May Help Push the Reframing Obesity Debate Forward.” American Journal of Public Health 105 (5): e38-42.

Puhl, Rebecca M., and Chelsea A. Heuer. 2010. “Obesity Stigma: Important Considerations for Public Health.” American Journal of Public Health 100 (6): 1019–28.

Tylka, Tracy L., Rachel A. Annunziato, Deb Burgard, Sigrún Daníelsdóttir, Ellen Shuman, Chad Davis, and Rachel M. Calogero. 2014. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” Research article. 2014.

Categories
teen eating disorder teen group

Teen Eating Disorder Recovery Group

 

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.

 

Categories
Family-Based Therapy teen eating disorder Uncategorized

When to Add an Individual Therapist in FBT-Phase 1

Photo by Priscilla Du Preez on Unsplash

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

Categories
Eating Disorders Family based treatment

Externalizing an Eating Disorder: When, Why, and How Do You Do That and Who is “Ed” Anyway?

Dalle-2

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.

Categories
Eating Disorders Family based treatment

How do I Parent My Teen During Family-Based Treatment? When to Set Limits

Photo by Jakob Rosen on Unsplash

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.

Recommended Reading

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

Categories
Eating Disorders Los Angeles

Low-Cost Eating Disorder Psychotherapy Now Available

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.

Categories
ARFID

Supporting Your Loved One with ARFID

by Carolyn Comas, LCSW, CEDS-S

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 your loved one has a phobia of vomiting, you can learn more about supporting them with that phobia.

Fifth is learning about diet culture and not making judgments about the preferred food choices of your person with ARFID.

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.

We provide individual treatment for teens and adults with ARFID and also have a FREE virtual adult ARFID support group for people in California.

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