In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team often also includes a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.
It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.
So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.
FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.
Comprehensive Dialectical Behavioral Therapy
Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.
DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.
Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.
For DBT to by comprehensive it must comprise the following components:
DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.
When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.
Exposure and Response Prevention
Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.
OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.
With the global COVID-19 pandemic shutting down not only towns and states but entire countries, our world has entered into an abnormal time. The lives of everyone have been interrupted and disrupted by a virus that can have devastating effects. During this time many people are reporting feeling levels of heightened anxiety and for those already struggling with anxious thoughts, this can be a paralyzing time.
It is natural to feel anxious during a worldwide pandemic. There is something scary out there and there are a lot of questions about what will happen, what the future will be like once we can return back to normal, and whether we can even return back to our old normal.
These thoughts and feelings remind me of when I lived in New York during the September 11th terrorist attacks. While an attack is far different than a virus, there are similarities in the feelings that arise. I, and many others living during that, questioned whether I was safe, whether this would happen again when it might happen again, and what would happen next. In the months and years to follow our style of living differed slightly. Most apparent was how the structure of airports and entering airports changed. Never again would you come off the plane to see family and friends waiting at the gate. And there were other changes that we all just adapted to which became our new norm. Life became known as living in “Post 9/11.”
I can only assume that we will one day live in a world “Post COVID-19” and move past this pandemic. But It leaves us all with numerous questions including: “Can I get sick? What will happen in the future?” Anxiety loves to live in the “what-ifs” and can cause increased fears and panic. So during this time, a time of uncertainty when many of us feel a lack of control, it is best to look at strategies to manage anxious feelings.
Limit triggering information. The news can be very triggering so try to limit your news consumption. Just as it was in 2001, the news is 24 hours a day and 7 days a week. However, now, it can be accessed not just by our computers, radio or television, but right on our phones. Too much information can be overwhelming. Try to limit your media intake to an hour a day and look at getting your information from legitimate sources. In this case, follow a single trustworthy news source or the Centers for Disease Control and Prevention (CD) or the World Health Organization (WHO). Pay attention to your local officials who are setting guidelines in the towns/cities that you live in.
Reach out for support. While right now we are practicing social distancing, you can still connect to people through phone calls, video calls, online game streaming services, and other social media outlets. Many therapists, dietitians, and medical professionals are offering video sessions. Many support groups have moved online as well. Support can be a click away. You do not have to sit with your thoughts all by yourself.
Practice grounding techniques. If you feel yourself having an anxiety attack try to focus on one sense (i.e sounds) and pay attention to what you hear around you. Or close your eyes and imagine a place that feels safe. Describe back to yourself this safe place and what you see, smell, hear, and feel.
Take deep breaths. Anxiety and panic can increase heart rates. Slowing down your breathing can help decrease the on-edge feelings. There are many great Apps and online videos that offer free-breathing techniques and meditations.
Focus on the present. Focus on what you are able to do right now. We do not know when things may start up again but think about the things you’d like to be ready for. A great example is if your school is paused right now, but you have access to many educational resources, that learning doesn’t need to end.
Lastly, engage in hobbies and activities that you enjoy. Allow yourself to have fun even during these trying times. Anxiety can steal our fun and relaxation so make sure you continue to do things that make you feel good.
It is okay to feel your feelings and it is okay to have anxious thoughts. The above list is a useful tool if you are finding yourself stuck in your anxiousness. While it is an unprecedented time, you can work on managing your reactions to your feelings and thoughts through these coping techniques. If you or someone you know is struggling, the clinicians at Eating Disorder Therapy LA are here to help. We are offering teletherapy sessions for those in California or New York state. For more information or to set up an appointment reach us at 323-743-1122 or e-mail Hello@eatingdisordertherapyla.com.
Family-Based Treatment (FBT) is the leading evidence-based treatment for adolescents with anorexia nervosa and bulimia nervosa. One of the common misbeliefs I hear is that it’s “only for kids or younger teens.” However, I think it has a much wider applicability. In fact, I would say that my FBT training has significantly improved my effectiveness in treating eating disorder patients of all ages.
While there have not been studies of FBT that pull it apart and pinpoint the elements that drive its success, I have a few theories. One of the key underpinnings of FBT is meal support. People with eating disorders experience such crippling anxiety before, during, and after meals that it is no wonder they would do anything they can to avoid eating. When the brain is in a state of overwhelming anxiety, a person with an eating disorder cannot make logical decisions about what to eat—or even to eat. And yet, without eating there can be no recovery. Treatment centers understand this—providing regular meals has been the mainstay of residential and partial hospitalization (PHP) eating disorder treatment for some time. FBT is the in-home parallel to this treatment.
In FBT, parents are charged with nourishing their teens back to health by providing regular nutrient-dense meals and preventing purging, excessive exercise, and other eating disorder behaviors. Parents plan, prepare, serve, and supervise meals and after meals, if purging is an issue. They make all the food decisions. They sit with their struggling child during those terrifying meals and help their teens cope with eating amounts sufficient for them to get well. Over time they return control to their teens, building their capacity to fight the eating disorder on their own. It takes effort and time to change brain pathways that have made eating a scary experience. For this reason, even those patients with eating disorders who go on to higher levels of care usually don’t remain there long enough to develop the autonomous ability to eat enough to sustain recovery. They often continue to need meal support for some time after more intensive treatment.
I think FBT has applicability that spreads wider than just children and teens. There is preliminary evidence of its successful use with transition-age youth up to age 25. Many parents have reported successfully using it with their college-age children. I have used it with this age and the primary variation is that the young adult plays a bigger role in their own treatment. They must agree at least in theory to accept their parents’—or other caregivers’—support. The young adult may choose who will support them during meals. Some, for example, may have a college roommate provide support. Some parents do meal support via FaceTime when the young adult lives far away.
I should clarify that FBT is a manualized evidence-based treatment. To be done with fidelity it must comprise certain components, including a therapist who guides the parents in organizing their strategies to fight the eating disorder. Parents refeeding their child without a therapist’s oversight often state they are “doing FBT”. In this case, it is more accurate to say they are providing FBT-informed or carer-supported feeding. Regardless of the words we use to describe this support and whether or not a therapist is involved, I think it provides a core benefit that we can expand to other populations.
These principles can also be applied to adult treatment. I personally have supported an adult who was in PHP during the day and needed more support with meals outside of treatment hours. I applied the skills I learned in my FBT training to provide meal support to this person. It worked just like it did with teens. Obviously this adult was an active participant in their recovery who asked for my support. This does not mean that I did not encounter the same kind of anxiety and resistance that parents meet around meals.
Take another case —a 20-something patient who still lives with her parents. She has been doing so much better since she asked for help, trading in the restrictive foods she had been eating on her own for several years for family meals prepared by her parents. Or the case of a college student who gets support via FaceTime from her parents who live in another city. When working with young adults with eating disorders who are in loving relationships, we often work to help their significant others develop strategies to support them during meals.
My experience is not unusual. Many other FBT-trained clinicians report success with providing FBT-informed treatment to people from all walks of life. One dietitian has reported great progress working with an employed single adult who moved home to live with his parents so they could support with meals. Sadly, previous providers had pathologized his moving home as a sign of enmeshment. One therapist shared, “I am doing FBT with a 79-year old. She is now in phase 2. She can now go out on dates—she just has to send pictures of her food to her adult children who are taking charge of her recovery and have been in charge of plating her food.”
Many have realized that in-home meal support is a common need for patients, and naturally, it is starting to become a big business with several treatment programs now providing this service. Offered as a service, this individualized meal support can be very expensive. Far more convenient, cost-effective, and loving is meal support provided by parents, other family members, or significant others.
I personally see it as a sign of strength when an adult admits they need more help. There is no shame in needing meal support during your recovery no matter what your age. Moving back home to live with family for support is nothing to be embarrassed by. This disorder robs people of their ability to make decisions around food—outside support is needed by definition. If you struggle around mealtimes with deciding what to eat, only feel safe eating a narrow range of food, have been struggling to make progress in your recovery, or cannot manage urges to purge after eating, you are not alone. You may benefit from the addition of meal support. It may feel scary or embarrassing to ask for help and you may worry you are being a burden. But asking for help is a brave step and you will likely find that there are some people in your life who can do this for you. It sometimes requires a little creativity, but you may find that it makes a big difference in your recovery.
The short answer is: FBT can be for people of any age.
Chen, E. Y., Weissman, J. A., Zeffiro, T. A., Yiu, A., Eneva, K. T., Arlt, J. M., & Swantek, M. J. (2016). Family-based therapy for young adults with Anorexia Nervosa restores weight. International Journal of Eating Disorders, 49(7), 701–707.
Dimitropoulos, G., Freeman, V. E., Allemang, B., Couturier, J., McVey, G., Lock, J., & Le Grange, D. (2015). Family-based treatment with transition-age youth with anorexia nervosa: a qualitative summary of application in clinical practice. Journal of Eating Disorders, 3(1), 1.
Dimitropoulos, G., Landers, A. L., Freeman, V., Novick, J., Garber, A., & Le Grange, D. (2018). Open Trial of Family-Based Treatment of Anorexia Nervosa for Transition Age Youth. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 27(1), 50–61.
This quote has generated a lot of reaction. In this podcast, Shira—who lives in a larger body when she is not using eating disorder behaviors—details how she has suffered from fatphobia in the world and in treatment centers. She shares that she has been significantly harmed by both well-meaning treatment providers and highly-regarded treatment centers.
This blog addresses two questions:
How is fatphobia affecting therapy and patients?
When is someone well enough to treat?
Shira is my friend and colleague. I regard her above quote to be a challenge to all treatment providers who have not faced their own fatphobia, including those who seemed afraid of Shira’s weight gain, tried to reassure her she was not gaining weight or would not gain weight, tried to help her keep her weight down, and limited her portions. These actions have harmed her by making her afraid to eat enough to sustain her healthy body weight and making her unable to fully recover after a 19-year history of an eating disorder.
Weight Stigma in Treatment
One incident Shira experienced in treatment was relayed to her friend, Sam Dylan Finch who described it in a blog post:
“The dietitian said, ‘You three get two scoops of ice cream.’ She then looked at me and said, ‘You’ll get a kiddie scoop.’”
Some of you won’t understand the gravity of that comment. To be clear, a dietitian told a patient with anorexia nervosa to eat less food than her peers, because she is a patient in a larger body.
The message here being, of course, that Shira needed to eat a child-sized portion of ice cream, because she wasn’t thin enough to “safely” consume more than that.
This plays directly into the eating disorder’s conviction that she needed to tightly control her food intake and her body. Her peers could eat a “normal” amount of ice cream. But she couldn’t and was singled out, because something was “wrong” with her body.
“This was the message I received my entire damn life,” Shira told me. “That I couldn’t eat like everyone else.”
— Sam Dylan Finch
The mixed messages of “eat ice cream” but “only a tiny serving” have further strengthened Shira’s eating disorder. The message treatment providers delivered over and over again was that her body needed to be controlled in order to avoid fatness. She yearned to be able to eat freely.
Shira also acknowledges that there were times in the past when she thought she was fully recovered. She only discovered years later after a relapse that what she thought was fully recovered was only partially recovered. How is this possible? Because we live in a culture where it is considered desirable and virtuous to maintain a low weight, deny ourselves tasty foods, limit the amount we eat, and exercise intensely. No other mental illness is so unfortunately reinforced by our cultural ideals.
And in terms of who is well enough to treat people with eating disorders, is recovery from one’s own eating disorder the only criterion that matters? How would we ever be able to vet that? How do we define recovery anyway?
I agree with Shira that there are many providers in the field who have not faced their own fatphobia. Focusing exclusively on providers who have had an eating disorder and whether or not they are recovered ignores a large portion of the provider community who do not have diagnosable eating disorders but may still be casualties of diet culture, wrestling with internalized weight stigma. These providers may be doing much more harm, but their impact has unfortunately received limited attention.
Providers With History of an Eating Disorder
Research indicates that a significant number of eating disorder treatment professionals have personally experienced an eating disorder. A study by De Vos and colleagues (2015) found that 24 to 47 percent of eating disorder clinicians reported a personal eating disorder history. An unpublished 2013 Academy for Eating Disorders online survey indicated that out of 482 respondents from professional eating disorder organizations, 262 (55%) reported a personal history of an eating disorder and half of those reported working directly with eating disorder patients. If we added subclinical eating disorders and disordered eating I have no doubt the rates would be higher.
Some have suggested over the years that providers with histories of eating disorders should never work in the field. This would be a mistake. Many professionals with their own personal histories (disclosed or not) have made major contributions to the field and to our understanding of eating disorders. Carolyn Costin, MEd, LMFT, CEDS and Mark Warren, MD, MPH, FAED are two public examples of prominent recovered professionals. In the broader field of psychology, one need only look at Marsha Linehan, Ph.D., who developed the leading evidence-based treatment for borderline personality disorder and other conditions based on her own experience of recovery from a severe mental illness to see that blanket restriction like this make no sense. In various surveys, patients have consistently reported it is helpful to work with providers who have had an eating disorder.
But even more complicated is the fact that we do not have a solid definition of recovery. In eating disorder research studies, recovery is often defined by three components:
Physical—BMI higher than 18.5 or another universal marker like expected goal weight;
Behavioral—absence of binge eating, vomiting, laxative use, or fasting; and
Cognitive—EDE-Q subscales about shape and weight concerns within 1 standard deviation of age-matched peers.
With dieting widespread (a 2018 study reported 36 percent of Americans were dieting), how many providers with disordered eating and their own extreme weight control behaviors go under the radar? How many providers may be engaging in their own intermittent fasting, keto diets, counting calories, or excessive exercise? I would agree with Shira that we should be equally if not more afraid of these providers.
Who is Fit to Treat Eating Disorder Patients?
If the field can’t decide who is recovered, who is to decide who is fit to treat eating disorder patients? Are therapists who acknowledge they have clinical eating disorders worse than fatphobic dieter providers who deny their own food issues and go on to shame patients, recommend any kind of dietary restriction, and limit the weight gain necessary for full recovery? How do we decide when someone is well enough to treat others?
The following quote from Carolyn Costin M.A., M.E.d., LMFT, FAED, CEDS and Alli Spotts-De Lazzer M.A., LMFT, LPCC, CEDS in their article for Gurze (2016), “To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder,” highlights an important point:
“Even if the field reaches its consensus on a definition of recovered—and then holds it up as the criteria for being able to be work with eating disorder patients—how would we verify a recovered status? Could standardized measuring and monitoring happen? When substance abuse facilities hire individuals who identify as recovering alcoholics or drug addicts, drug testing can verify if the person is considered clean and sober or ‘using.’ There is no similar test to determine if a person is ‘using’ his or her eating disorder symptoms. Some have suggested that therapists with personal eating disorder histories be subjected to clinical eating disorder assessments and ultrasound checks for ovarian size to determine if they are at a healthy weight (Wright & O’Toole, 2005). Without even discussing the actual merit of these as determining factors, would these tests be administered to all therapists who wish to work with eating disorders or just those who say they once had an eating disorder? And couldn’t those with an eating disorder history be able to avoid such testing by not disclosing they ever had an eating disorder?”
Costin and Spotts-De Lazzer go on to state, “It seems interesting and confusing that there could be so much proposed attention on therapists who have recovered from an eating disorder but not for therapists who have histories of depression, anxiety, post-traumatic stress disorder, or another diagnosis in their past.”
Perhaps we should be focusing on assessing providers for awareness of weight bias instead.
Further, if we shame Shira for being a provider with an eating disorder, how do we make it safe for other providers to acknowledge their own struggles and receive help if they have a lapse or relapse? Shira has reported that a significant number of providers have shared with her that they have struggled or are currently struggling. This says a lot.
So back to the question—how do we decide when someone is well enough to treat others?
I don’t have the answer to this question. The field has been unable to even define recovery.
Am I more afraid of fatphobic dieting therapists who may not be aware of their potential for harm than therapists who believe in and espouse Health At Every Size ® while acknowledging their own mental illnesses? Ultimately, yes, I am.
I think we need to look inward and address the rampant weight bias in the field. With dieting so widespread we have a lot of work to do. I believe everyone deserves treatment to full recovery and safety in their bodies. We need to address structural issues that limit access to care and safety. We need to make it safe for providers to receive help for eating disorders. I think it behooves every professional working with eating disorder patients to look at their own weight bias and work to practice from a weigh-inclusive approach. Only this way can we reduce the harm done to people like Shira.
Costin, C. & Spotts-De Lazzer (2016). To Tell or Not to Tell: Therapists With a Personal History of an Eating Disorder. Gurze Salucore, Eating Disorders Resource Catalogue.
Stych, A (2018). Percentage of Dieters More Than Doubles. Bizwomen: The Business Journals.
Have you been tracking your food via a calorie-counting app?
Maybe you’ve been tracking your exercise through a wearable or other system. Did you know such tracking:
May encourage a disordered relationship with food and your body?
May actually be jeopardizing your health rather than helping you to monitor it?
If you’ve noticed that you’re becoming obsessive about what you eat or how you move your body, it might be a good idea to examine your relationship with any tracking devices you are using.
People may track their weights, food consumed, and workouts in the name of health. But for many people, tracking such data can actually be detrimental. Preliminary research shows that the use of MyFitnessPal can contribute to eating disorder symptoms in undergraduates (Simpson & Mazzeo, 2017), adults with eating disorders (Levinson et al., 2017) and men (Linardon and Messer, 2019).
The research is not clear about exactly why these devices can be so detrimental. In my experience working with patients with eating disorders who track, tracking cuts people off from their bodies and their own regulatory systems. People who track become reliant on objective measures and data for making decisions about how much to eat and how hard to exercise. They lose awareness of their own bodies’ signals. Perfectionistic traits may drive them to eat fewer calories, take more steps, and increase their distance or pace during a workout. Even those who don’t struggle with a diagnosable eating disorder can be negatively impacted by these tracking devices and apps, with individuals who previously had a perfectly normal relationship with food suddenly feeling completely consumed with thoughts about what they’re putting into their mouths.
This was brought home to me when working with a patient who was obsessively tracking his workout metrics. As we discussed doing a bike ride without his fitness monitor–just as an experiment to see how it felt—he argued passionately with me, with one telling objection being, “How will I know when to take a drink?” He had been timing his consumption of water according to time and distance.
I asked him the same question back: “How will you know when to take a drink?” Hearing it from a third party, he realized how strange the question sounded and how disconnected he had become from his own body.
Similarly, patients who count calories and carefully dole out lunches of specific caloric allotments become frightened when faced with a lunch of unknown (and likely higher) caloric value. Knowing that restaurant portions are larger and more calorically dense then the meals they make at home, they ask me how they can possibly avoid overeating. And then they are amazed when they find that they are sometimes satisfied with less than the entire portion of the restaurant meal, precisely because it’s more calorically dense and satiating.
Once they are no longer eating according to self-imposed strictures, eating becomes a different experience. They gain the capacity to tune in to how they feel while eating the food, rather than just eating to completion of their allotment–and they find that their bodies tell them when to stop eating. Life without tracking can become a freeing and enjoyable experience in which you can be fully present during meals and exercise and engage with the people around you and your surroundings—having deep conversations without intrusive thoughts and becoming mesmerized by beautiful surroundings when you exercise outdoors, for example.
Our bodies are wonderful, self-regulating mechanisms. Our bodies tell us when we need to urinate or have a drink of water or when it’s time to eat and when it’s time to stop eating. When we succumb to diet or wellness culture and stop trusting our bodies and start relying on external systems to tell us when to drink or how much to eat, we become disconnected from our bodies and we lose the ability to recognize these signals.
How to Stop Tracking
If you find that you are obsessively tracking your food or workouts, I invite you to try the following experiment:
Fitness tracking: do one workout without your monitor. During and after your workout, rather than looking at your metrics to evaluate the workout, ask yourself instead how your body feels/felt during the movement and afterward.
Food tracking: eat a meal where you do not know the caloric content. Tune in to how you feel while eating it. How does it taste?
Levinson, C. A., Fewell, L., & Brosof, L. C. (2017). My Fitness Pal calorie tracker usage in the eating disorders. Eating Behaviors, 27, 14-16.
Linardon, J., & Messer, M. (2019). My fitness pal usage in men: Associations with eating disorder symptoms and psychosocial impairment. Eating Behaviors, 33, 13–17.
Simpson, C. C., & Mazzeo, S. E. (2017). Calorie counting and fitness tracking technology: Associations with eating disorder symptomatology. Eating Behaviors, 26, 89-92.
A difficult concept in recovery is knowing when to let go of an activity or even a job that could potentially re-ignite the eating disorder. As a therapist I find myself guiding my clients towards the realization that the sport or career path they had loved so much might be the very thing that holds them back and sets them back up for relapse. It isn’t always an easy decision.
Letting go of something that may have predated the eating disorder can lead to questions as to why it cannot remain in someone’s life in recovery. Many clients in the early stages of eating disorder treatment have to face the fact that they have to stop their sports if they are trying to regain weight or are working on eliminating behaviors that could leave the body physically weak. It is no surprise that once stabilization begins there is an urge to return to previously enjoyed activities. However, returning to these activities could potentially hinder full recovery.
Sports like gymnastics, running, figure skating, wrestling, and dancing are incredibly wonderful. As a figure skater myself, I can attest there is no greater feeling than gliding over the ice. But these same sports, especially at the elite level, can be incredibly demanding on the body. Behaviors required for full recovery can go against what a coach may be preaching to athletes to be in top physical form. What is expected of top athletes could look like disordered eating and poor body mentality from an outside perspective. The eating disorder itself may take what is used to condition a top athlete and manipulate it for its own gain.
It can be difficult to find the balance between a recovered mindset and meeting the demands of a sport or career. With some of my clients in the entertainment industry, there are pressures to look a certain way and fit a mold that their bodies may not be meant to fit. It can be difficult to navigate knowing they need to eat a certain amount of times a day and then have an agent say, “Lose five pounds for this role.”
The hardest decision is when there is a realization that staying in either the sport or career is just too detrimental to your health. It is certainly not easy to walk away from something you’ve put work into. And that can also be said about your recovery. Are you willing to give up a healthy body and mind for a potential chance at a gold medal or lucrative career even if it means killing yourself along the way? I’ve worked with a client who was a dancer who recognized as she was going through treatment that going back into a dance studio would be too triggering. She knew that staring at herself in a mirror and comparing herself to her classmates would lead to restricting her meals. It wasn’t an easy decision to walk away, but she knew there was no way she was in a place to be able to dance without being triggered.
In some circumstances, you may not have to completely quit your previous passion. You might be able to approach the activity differently. You may not be able to return to a sport as an elite athlete, but you could still engage in the activity at a more recreational level. I’ve seen some of my clients shift from being an athlete to being a coach. Actors going from television and movies to doing local theater. Sometimes you can still do what you love but it just needs to be re-configured to fit into your recovery lifestyle. For many, it can be comforting to know they can still act or model or run, but just do it less intensively.
You may also have the option of challenging what a sport or career emphasizes as far as body image and diet pressures. There are many models and actors who are embracing bigger bodies and not letting the pressures to lose weight define them. With this option, there is a risk of rejection along the way as we do still live in a culture that overvalues thinness. With that being said, this may be a safe option primarily for those who feel stable in recovery and are able to actively use coping skills to fight urges. If your recovery has reached a place of advocacy this definitely could be a path to take.
Leaving a passion behind or re-defining how it fits into your life can be a huge change. You may feel sad or mad. That’s okay. Ultimately, the decision you make will be the one that supports you in your recovery. If staying in the activity is going to trigger calorie counting, weekly weigh-ins or criticism for not looking a certain way, is it worth it? If you know where the eating disorder thrives then why play with fire? Ultimately, the decision will be based on what will make you healthy and happy and not allow you to compromise with the eating disorder.
For many of my patients who have firmly joined the anti-diet camp and embraced a Health at Every Size approach® (HAES) to health, dealing with family members entrenched in diet culture can be a minefield that is tough to navigate. Let me say that I get it! I also have friends and family members who remain focused on thinness and weight loss. It’s hard!
I notice that for many of my patients, it feels like HAES opens a huge chasm between their beliefs and the beliefs of their family members. It’s an entirely different world view. In fact, the only parallel situation I have observed is the divide between patients who are liberal in their political beliefs and their conservative family members. There is almost no bridging the gap. They cannot see eye to eye and they feel no political discussion with these family members is safe.
If you feel the HAES paradigm has been personally helpful, you grow eager to share your knowledge with family members. You may want to help release them from their own diet prisons as well as transform them into HAES advocates and supporters for your health.
However, I recommend setting modest expectations. You have probably worked hard at recovery, meeting with a HAES treatment professional, reading, studying, and doing the work. You have spent countless hours on your personal journey breakup with diet culture. This has been a long and involved personal process.
Consider your family member: they have not invested the time or energy in this project that you have. They are probably still wedded to diet culture. They are not likely to be swayed merely by your testimonial that HAES has been helpful for you. After all, they still get diet messages everywhere they turn. They have been absorbing these messages for many years.
People rarely disavow diet culture immediately upon learning about HAES. I know this because I know the process you have been through. Even as a professional immersed in the eating disorder world, my own evolution to a firm HAES stance developed over a period of about 5 years. I see with my patients too that it is a process. Some aren’t ready to let go of diet culture and don’t return after a first session when I convey that I do not support the pursuit of weight loss. For those who stick with treatment, it can take many months to evolve into a HAES adherent.
Your exuberance about HAES may fall on flat ears. Remember this chasm between HAES and diet culture is just as vast as that been liberals and conservatives. So, I recommend taking a page from the people I’ve worked with who have a political divide in their family: set your expectations and Agree to Disagree. Use radical acceptance. Do not focus on proselytizing your family members. This can lead to conflict and disappointment.
You can let family members know that you have given up dieting. Do not expect them to do the same. You can offer them information about HAES by sharing some articles or favorite blogs or podcasts but do not expect they will read them. Be happy if they do, and offer to discuss these ideas if they want to. Be satisfied if they accept the recommendations. Practice empathy for their perspective; they are a victim of diet culture just as you once were.
Focus on setting a healthy boundary. You can ask them not to comment on your body or comment on your eating in your presence. This request is not hard for them to meet. You can also ask that they try to refrain from diet talk in front of you. Over time, you can remind them and train them.
I know from experience. I have been at this with my family and friends for years. I have a close family member who continues to be diet-focused but for the most part, knows they cannot discuss this in front of me. Recently, they told me (several times) about how a friend had lost so much weight and how great it was. I told them I was not interested in hearing about their friend’s weight loss. They told me, “Oh, I forgot who I was talking to.”
One of the cardinal rules of dieting is “Eat only when you’re hungry.” I often find that the fear of eating when not hungry is one of the most difficult bits of dogma to overcome. People with eating disorders and good dieters everywhere have been taught that this is all that stands in the way between us and complete loss of control and utter disaster in our lives. Many don’t even see it as an actual choice or symptom of the eating disorder.
Successful recovery from an eating disorder or disordered eating or chronic dieting requires overcoming and challenging this rule.
Just off the top of my head, I can think of a lot of reasons to eat when not hungry. Here are a few related to disordered eating:
You have overridden your hunger cues for years from cycles of dieting, bingeing and purging. You don’t recognize normal hunger cues or satiety. Your treatment team has told you to eat regularly—three meals and two to three snacks per day. You feel like it is too much food and you’re not hungry. Should you follow their meal plan? Yes! Eating regularly is a crucial step in recovering from any eating disorder and it helps to regulate your hormones and circadian rhythms so you can regain your hunger and satiety cues and become a more intuitive eater.
You are in recovery from a restrictive eating disorder and rarely feel hunger. You are told you need to eat more, but you don’t believe it. Isn’t it better to delay eating until later in the day? Should you really eat breakfast and lunch at the times scheduled by your dietitian? Yes, absolutely! Regular meals are critical to getting all of your body functions to work properly again. One of the reasons you may not be feeling adequate hunger could be delayed gastric emptying, which occurs when someone is undereating and food remains in the stomach far longer than it should. One of the consequences is low appetite. The solution: eat regularly as prescribed, even if you’re not hungry.
I can think of many more situations that apply to all of us, not just those with eating disorders:
You normally eat dinner at 7 pm and your circadian rhythm is conditioned to get hungry then. But your sister has scheduled a family dinner at 5:30 to accommodate her children so they won’t be cranky at the table. Should you eat at 5:30 before you are hungry? Absolutely! Adjusting our schedules allows us to have meaningful social interactions that typically revolve around eating.
You have a meeting that is scheduled from 12 to 3 pm. You’re not hungry at 11 am; breakfast was only at 8:30. You have the option to have a proper lunch at 11:30. Should you? Of course! Be practical—it’s better to eat before your meeting. Then you’ll be properly fueled and will be better able to concentrate during the meeting. Our brains don’t function as well when they’re low on glucose. Planning ahead and adjusting mealtimes accordingly is an important act of self-care.
You are traveling to another country. You arrive at your destination and it’s dinnertime. Your circadian rhythms are all thrown off. You feel like you’ve been eating constantly. Should you eat? Yes! Acclimation to a new time zone is ushered along by institution of regular eating at the times appropriate to the destination. You will adjust faster if you get your body in synch.
You just had a rough breakup. You’re eating meals, but sad. Your friends show up and want to take you out for ice cream to cheer you up. You’re not hungry. Should you go and eat ice cream with your friends? Absolutely! Food is not solely about nutrition – it’s also about bonding and comfort, and you should let the ice cream and your friends soothe your broken heart.
You’re stressed and preparing for a presentation tomorrow. You’ve eaten adequately throughout the day and are not truly hungry. But you know that crunching on some popcorn will soothe your nerves. This is an old behavior that you’ve overused in the past. Contrary to popular belief, emotional eating is not itself a problem. Food is our earliest comfort and humans are designed to find food to be rewarding. If it were not, we would have died out as a species. There is no shame in using food as comfort—what can be problematic is if there are no other tools in your emotional toolkit. If eating is your only coping skill then I encourage you to learn some other strategies for managing negative emotions to give you a broader range of alternatives.
So, not eating when you’re not hungry is a rule that should be confronted. How can you start to challenge this rule and, if you have one, the eating disorder that uses it as an excuse?
You must face it head-on with new behaviors, deliberately defying it. If you have been instructed to follow a meal plan: follow it. If you have been told you are undereating: practice eating one thing per day when you are not hungry. The next time you have something in your schedule that interferes with a normal meal time: eat beforehand. Accept invitations to eat at times to which you are unaccustomed. Eat something spontaneously when it shows up, even if you are not hungry.
By practicing these behaviors, you will become less fearful of eating when not hungry. You will learn that this, too, is a normal part of being a human. You will be more relaxed around food and you will see that nothing horrible happens if you eat when you’re not hungry. You do not have to continue to be a victim of diet culture.
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.
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.
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:
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 their 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
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.