Do I Need to Quit X to Stay in Recovery?

Do I Need to Quit X to Stay in Recovery?
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By Carolyn Hersh, LCSW, Staff Therapist

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.

When You Have Adapted a Health At Every Size Approach and Your Family is Still Stuck in Diet Culture

When You Have Adapted a Health At Every Size Approach and Your Family is Still Stuck in Diet Culture
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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.”

That’s how you train family members.

Read more: To the Family Member Who Worries I Am Not Helping Your Loved One’s “Weight Problem”

Seven Reasons You Should Eat When You’re Not Hungry

challenging diet rules
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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:

  1. 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.

 

  1. 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:

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

 

  1. 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.

Participating on an FBT Team

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

Overview of FBT (3 phases)

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

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

FBT consists of three phases:

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

When to Add Other Providers

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

Family-Based Treatment Teams

Dietitians

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

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

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

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

Individual Therapists

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

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

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

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

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

Advice for The Individual Therapist

My advice for the individual therapist:

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

 

When Your Child With an Eating Disorder is Sick….

Guest post by Dr. Jennifer Johnson

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

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

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

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

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

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

What about if they have a fever?

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

What about when kids in recovery have the stomach flu?

What do you do if they’re vomiting?

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

What about diarrhea?

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

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

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

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

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

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

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

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

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

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

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

Parent Volunteers Needed for Eating Disorder Recovery Research Study

Parent Survey Eating Disorder

 

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

Parent Survey of Recovery

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

This survey is for parents who:

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

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

Study Information

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

Principal Investigator: Jocelyn Lebow, Ph.D.

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

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

 

The researchers

Recovery When Grieving by Carolyn Hersh, LCSW

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

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

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

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

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

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

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

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

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

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

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

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

This Halloween, Serve Candy to Your Teen in Recovery

A Family-Based Treatment (FBT)-approach

Fear FoodFor teens with eating disorders, Halloween can be scary for the wrong reason: the candy! Most teens with eating disorders are only willing to eat a restricted range of foods. Expanding this range is an important goal of treatment, with the reintroduction of fear foods being a key step. Candy tends to be high on the fear food lists of many teens.

Halloween presents an ideal opportunity.

A Taste of Recovery

Most teens in America are excited for Halloween and its bounty of candy. By incorporating some candy during your teen’s Halloween week you can help them approximate the lives of teens who do not have eating disorders. This step can give them a taste of the full life you want for them—a life where they are unencumbered by food restrictions, a life where they can enjoy all foods, a life where they can travel the world confident that they will easily be able to meet their nutritional needs, and a life where they won’t feel the need to shun social events for fear of facing the foods there.

I know that I’m painting a beautiful picture and that this is easier said than done. Teens with eating disorders will deny that the disorder is driving their food preferences. Instead, they claim they simply don’t like candy anymore. Or that candy was the preference of a child and since then their palates have matured. But don’t believe them—you have crucial parental memory and knowledge. You know which foods your teen actually liked a few years back. You also probably know the foods on which he or she binged if they binged. And it is not credible that any teen really hates all candy!

Especially if your teen had a great many fear foods, you may already have experience reintroducing some of them. But once meals start going more smoothly, some weight has been restored, and binges and purges have subsided, many parents are reluctant to push further. Why rock the boat when your teen seems to be doing well? You may be wondering: Is candy really necessary?

In fact, this Halloween is exactly the right time to introduce candy.

Exposure

It is much easier to introduce fear foods before your teen is completely independent in their eating. Right now, you are still overseeing meals and your teen does not yet have their independent life back. Pushing the issue of fear foods becomes more challenging when your teen has regained most of their freedom.

When you introduce fear foods to your teen, you will probably feel anxious. Your teen will too. You may even feel like you are going back a step. This is how exposure works—it is supposed to raise your teen’s anxiety. When your teen avoids these fear foods, their anxiety decreases, reinforcing the avoidant behavior and justifying the anxiety response. This perpetuates both the emotion and the behavior. But the food is not truly dangerous—if the teen were to eat the food, they would learn that nothing catastrophic happens. In exposure, the teen is required to eat the food, and the anxiety response shows itself to be baseless. With repeated exposure, the brain habituates, learns that the food is not harmful, and loses the anxiety response.

Exposure works through repetition over a sustained period of time—not all at once. It’s likely that each food on your teen’s feared list will need to be presented several times before the thought of eating it no longer causes extreme anxiety.

You may feel that requiring your teen to eat candy is extreme. However, remember: the healthy part of your teen probably wants to eat candy, but the eating disorder would beat them up if they ate it willingly. By requiring your teen to eat candy, you are actually granting your teen permission to eat it—permission they are unable to grant themselves. After recovery, many teens report that they really wanted the fear food but were too afraid—it was only when their parents made them eat it that they were able to.

And I would argue that fearlessness in the face of candy is important for your child. So be brave about facing potentially increased resistance by your teen and model facing your own fear.

Here’s How to Incorporate Candy During Halloween:

  1. Choose a few types of candy based on your teen’s preferences about three years before they developed their eating disorder. (If you can’t remember, ask one of their siblings or just pick a few options, maybe one chocolate-based and a non-chocolate alternative.) Make your choice based on providing your teen with the typical American teen experience. (American teens will typically collect a lot of candy on Halloween, have a few pieces that night, and then have candy as snacks a few times during the following week.)
  2. You may choose to tell your teen about the candy ahead of time or not. Some families find that telling teens about exposure to fear foods ahead of time is helpful; other families find that it is better to just present a fear food without warning. But note that you are not required to ask their permission; FBT is a parent-driven treatment.
  3. Serve a single serving of candy during dessert or snack a few times during the week of Halloween. Plan carefully and be thoughtful. Do this with the same resolve that you use when you serve them any starches or proteins. You may want to introduce the candy on a day when you feel more confident, will have more time to manage potential resistance, or can be sure a second caregiver will be present. You may not want to present candy, or any fear food, before an event that you are not willing to miss in case you encounter an extreme reaction.
  4. If your teen binges or purges, make sure to sit with them for an hour after they eat the candy.
  5. Plan for what will happen if your teen refuses to eat the candy. For example, will you offer something else instead and try the candy again tomorrow? Offer a reward for eating the candy? Create a consequence for noncompletion? Whatever you decide, be consistent and follow through.

If you do this-this year, there is a good chance that by next Halloween your teen will be eating candy independently!

Is the (Eating Disorder) Treatment Your Child is Getting FBT?

When new families talk to me about Family-Based Treatment (FBT), I often find that they are confused about what it is and what it isn’t.

FBT is a type of evidence-based treatment for adolescent eating disorders. This treatment was developed at the Maudsley Hospital in London in the 1970s and 1980s; Doctors Lock and Le Grange manualized it into its current form in 2001. Because of its name, FBT is often confused with more general “family therapy.” Be careful, because these are not the same thing—while both involve the family, FBT is a very specific, behaviorally-focused therapy.

While a treatment that includes some elements of FBT—but falls short of the full manualized treatment—may work for some eating disorder cases, it may not work for more difficult cases. When FBT doesn’t work it is important to know whether the child has had an adequate course of the true treatment in its evidence-based form. This can be tricky—in the field of psychotherapy, most therapists identify as eclectic, meaning they adhere to no single therapeutic orientation but combine techniques from several (just scroll through any Psychology Today therapist profile to get a taste for how many different theoretical approaches most therapists endorse). We don’t yet know which elements of FBT are critical to its efficacy and make it such a successful treatment. This would take expensive dismantling studies in which different partial treatments are tested against each other. Except for studies documenting a separated FBT (where only the parents attend sessions), no such study has been cited in the literature. Until we have good evidence that suggests otherwise, treatments that stay true to the original, already-tested treatments are the safest bet.

I once worked with a patient with panic disorder who had had previous treatment. He told me that his previous therapist had conducted cognitive-behavioral therapy (CBT), widely accepted as the best evidence-based treatment for panic disorder. When I dug deeper, I found that his therapy had included no exposure to the sensations of panic—considered to be the core element of CBT treatment for panic disorder.  Instead, the treatment had focused on discussing his anxiety thoughts—a very different protocol. From this experience I learned to inquire carefully about the treatment my patients have previously received before accepting that it cannot work for them.

So it is with Family-Based Treatment. Sometimes parents tell me that they think they tried FBT but are not sure. If your child was treated in an academic center, it’s more likely they got the evidence-based treatment of FBT in its full form. However, some parents who tell me that FBT didn’t work also tell me:

  • They did FBT on their own, with no therapeutic support
  • They had meals with their child, but that the therapist met primarily with the adolescent alone
  • They didn’t supervise all meals because their child resisted it. 

In each of these situations, it is obvious to me that the treatment is not what I would consider FBT. And while it is true that including some aspects of FBT or even a “watered down” FBT may be better than no FBT or parent inclusion at all, it’s important to know whether your child had the real thing or not, especially if they end up needing more or different treatment.

Often, parents who tell me they struggled with renourishing a child on their own find that things go much better once they started working with me or another therapist. That’s not to say that parents should never try to renourish a teen on their own—just that supporting a child with an eating disorder is extremely hard work and best done with the support and guidance of a professional at their side.

Signs Your Child Received FBT

Accordingly, I created the checklist below for parents to determine whether the treatment their child received (or is receiving) is really FBT. To how many of the following statements can you answer “YES” (the more the better)?

  • My therapist received training through the Training Institute for Child and Adolescent Eating Disorders.
    • The basic training is a 2-day workshop. Have they attended one?
    • Have they received or are they receiving clinical consultation or supervision by a staff member of the institute?
    • Are they certified in FBT by the Training Institute (meaning they have completed the 2-day training and received 25 hours of consultation by a staff member around their treatment of 5 patients)?
  • My therapist owns, seems familiar with, and refers to the FBT treatment manual.
  • My therapist refers to and acknowledges the three phases of FBT:
    • Phase 1 —full parental control
    • Phase 2 — a gradual return of control to the teen
    • Phase 3 —establishing healthy independence
  • My therapist is familiar with the work of Drs. James Lock and Daniel Le Grange, developers of the FBT treatment.
  • My therapist adheres to the five principles of FBT:
    • I was specifically told I was responsible for restoring my teen nutritionally and interrupting behaviors that interfere with recovery (including bingeing, purging, and overexercise). I was specifically told I was responsible for planning, preparing, serving, and supervising all meals.
    • I was told we don’t know for sure what causes an eating disorder and it doesn’t matter.
    • Initial attention of treatment focused solely on restoring health including weight gain and stopping eating disorder behaviors.
    • Rather than being given prescriptive tasks, I was empowered to play an active role and to discover those strategies that worked best for my family and the child whom I know best.
    • I was taught to externalize the illness and see it as an outside force that has hijacked my child, threatens his or her life, and makes my child do things he or she wouldn’t normally do. My child did not choose the eating disorder.
  • I have had a family meal at the therapist’s office.
  • My therapist spends most of the time with the full family, meeting only briefly with the adolescent alone at the beginning of the session (or in the case of “separated FBT,” all of the time with parents).
  • My therapist or another member of the treatment team tracks my child’s weight and gives me feedback after every weigh-in on how he or she is doing.
  • I was specifically told I am responsible for supervising all meals and snacks to ensure completion. If purging has been a problem, I was told to supervise the child after eating to prevent purging.
  • If my child has been exercising excessively, I was told to prevent this.
  • After weight was restored and bingeing and purging and other behaviors had ceased, my therapist guided me in gradually returning my teen control over their own eating.
  • I was told it was important to be direct with my teen about eating adequate amounts of food.
  • My therapist discusses the importance of both “state” and weight to recovery—meaning my therapist explains that weight recovery is a step towards psychological recovery, but not an end goal in itself.

Dead giveaways your child did not get FBT

Below are some indicators that your child might not have “gotten FBT” and might be receiving some conflicting messages:

  • I have been told that we, the parents, had caused the eating disorder.
  • My therapist spends the majority of therapy time alone with the teen.
  • My therapist spends a lot of time talking about the past and reasons my child wanted, needed, or otherwise developed the disorder.
  • A dietitian has met alone with my teen and given him or her nutritional recommendations.
  • My child has been given a meal plan.
  • I have been told that it is an option to not supervise all meals or prevent all purging.
  • The FBT therapist has provided individual CBT, DBT, or ACT with the teen during the weight restoration phase.
  • I have been told from the start of treatment to “not be the food police” (in FBT, this might happen toward the end of treatment, or in Phase 2 with an older teen).
  • My child has been in charge of making his or her own meals from the outset of treatment.

Summary

In conclusion, FBT has been proven to be the most effective treatment for adolescents in clinical trials. That said, not every treatment works for everyone. In my opinion, it is best to start with something that has a backing and then try something else if that doesn’t work. When you have sought out an evidence-based treatment, it’s important to make sure you’re getting the treatment in its researched form.

August 2018 LACPA Eating Disorder SIG Event

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

Presenter: Jaye Azoff, Psy.D.

Title: The Anatomy of a Recovery

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

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

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

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

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

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

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

RSVP to:  drmuhlheim@gmail.com

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