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Health at Every Size

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

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

How Diet Culture Impacts Eating Disorders

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

Research on Weight Stigma

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

Research on Weight Loss

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

What is Health at Every Size®?

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

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

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

What Research is there in support of HAES®?

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

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

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

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

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

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

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

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

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

How Can I Learn About HAES?

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

Websites

Video:

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

Books:

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

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

Sources

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

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

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

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

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

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

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ARFID

ARFID Parent Support Group

We welcome parents of youth 10 to 20 with Avoidant Restrictive Food Intake Disorder (ARFID) to our virtual support group.

Parenting a young person with ARFID is challenging. Feeding a young person with ARFID is extremely challenging. Meals may feel like a constant struggle. You have likely been given conflicting advice about whether to cater to their food preferences or not. You may feel like you’re running ragged searching for their preferred brand of yogurt or chicken nuggets or having to bring home the exact right fast food every night. You may have run out of ideas for what to serve them. They may be eating the same eight foods over and over again and the list of foods they are willing to eat only seems to get smaller over time. You feel worried about their health and you know they are not getting enough nutrition.

We have been supporting parents in supporting their teens with ARFID. Our work is rooted in Family-Based Treatment for adolescent eating disorders and Cognitive-Behavioral Therapy for ARFID. In our work with families of teens with ARFID, we see how hard it is to parent and feed and support recovery. This is why we have created a monthly support group for parents of teens with ARFID.

This monthly group is alternately led by Lauren Muhlheim, Psy.D., CEDS-S and Carolyn Comas, LCSW, CEDS-S over zoom. We will provide psychoeducation about ARFID, the different types of ARFID, how it may develop, maintaining factors, and recovery strategies. Parents will be able to share struggles and successes.

To Register

For more information about the group, please contact Hello@EatingDisorderTherapyLA.com or you may register for the monthly group (priced at $30) on our group page. (Please be sure you are registering for our monthly ARFID Parent group and NOT our free weekly Adult ARFID group.

 

Below are some strategies for supporting your teen with ARFID:

 

Categories
Dieting Eating Disorders Family based treatment teen eating disorder

What Parents of Teens with Eating Disorders Need to Understand About Diet Culture

Body Liberation Photography

 

Many parents experience guilt when their teen is diagnosed with an eating disorder. Nearly every parent can point to a time they themselves dieted, opted not to have a dessert they really wanted, expressed a preference toward thinness, or discouraged their child from keeping eating. You may have done things to try to keep your teen’s weight down and you likely did it with love and good intention—to protect your child from weight stigma and perceived subsequent health and social consequences.

It is common to wonder whether such actions contributed to the development of your teen’s eating disorder. Guilt is common for parents to experience when their child has any illness. In the case of eating disorders, many of the behaviors that are part of the disorder are reinforced by our culture’s preference for thinness and so blame is even more compelling.

What is Diet Culture?

Diet culture is a system of beliefs that values thinness and promotes it as a way to increase one’s worth. It creates rules about what type of eating is “healthy” and oppresses people who don’t meet the thin ideal.

Diet culture messages are everywhere, so it’s not your fault that you’ve absorbed them and subscribed to these beliefs without ever thinking twice about them. Diet culture is the soup in which we all swim. It’s the dominant paradigm. You likely have heard fear-mongering messages from other health professionals. You see it in the news.

Why is this system of beliefs so dominant? It’s promoted by a $70 billion diet industry. It’s entrenched in our fatphobic healthcare system. It’s reinforced by the media.

Parents often become the unwitting messengers of the dominant cultural message they hear from other health professionals. But this is an important turning point. Now that you are helping your teen with an eating disorder, it’s time to question what you think you know about health and weight and eating. You were not born hating your body. You developed these beliefs and you can unlearn them. It is never too late to start unlearning and unsubscribing to diet culture. We want you to join us in helping to break down the institutions that reinforce fatphobia and contribute to the development and maintenance of eating disorders and make your teen’s recovery harder. Your teen needs you fighting for their liberation.

We believe that parents are important allies for their teens with eating disorders. Even if you have disparaged your own body, dieted, cheered when your teen started eating healthier, or encouraged them to exercise in the early development of their eating disorder, we want you to know that you are not to blame for your teen’s eating disorder. Please show yourself compassion. Your teen needs you.

How to Do This

  • Learn about how health is much broader than weight. Read the resources on our website about Health at Every Size ® to expose yourself to messages that challenge the weight-normative paradigm.
  • Stop talking critically about any body, including your own body and especially fat bodies. Model body appreciation and respect for all bodies and for body diversity.
  • Accept that your teen likely needs to gain weight and examine your fears about what that means for them and for you. Read our article on recovery weights.
  • Encourage your teen to see fat not as something to be feared. We don’t want to reinforce what the eating disorder is afraid of. We need to make it safe for people to be fat.
  • Curate your social media feed. The mainstream media images we see are not diverse, and the images we do see of larger bodies are often portrayed in a particularly negative and stigmatizing way, adding fuel to the fire. One way to build your own acceptance of body diversity is to acclimate to seeing a broader range of bodies portrayed in a desirable way.
  • Refrain from categorizing foods as healthy or unhealthy, good or bad. Model eating a variety of foods including foods you may have previously demonized, including desserts. Model eating with enjoyment and the social connection that comes from sharing meals.
  • If you previously promoted leaner, restrictive or “healthy” eating and are worried about creating confusion or appearing hypocritical with a new message around more flexible eating and more calorically dense foods, you can unapologetically explain to your teen that, in light of their eating disorder and what you are now learning, that you are also working towards a broader understanding of health and nutrition and becoming a more flexible eater. Some of the more powerful situations I’ve encountered include when a parent shares their own process in rethinking their relationship with food and their body while simultaneously doing their own work alongside their teen in recovery.
  • Teach your teen to think more critically about health and media messages they observe.
  • Take the Weight Implicit Association Test. Be gentle with yourself and remember we all have weight bias.

It’s never too late to change your thinking about weight and food. Many parents of teens who’ve had eating disorders have become great advocates for size diversity. Please join us in the anti-diet movement.

Categories
Eating Disorders Family based treatment

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

Photo by Yaopey Yong on Unsplash
Externalizing an eating disorder is a therapeutic strategy that became more widely known through Jenni Schaefer’s book Life Without Ed, cowritten with her therapist Thom Rutledge. The book summarizes Jenni’s recovery from an eating disorder.

Jenni describes how in her treatment she learned to personify the eating disorder as “Ed,” an abusive boyfriend. As explained in the blurb on her website, “By thinking of her eating disorder as a unique personality separate from her own, [she] was able to break up with Ed once and for all.” The book details the various exercises she used in her recovery, including creating a formal “divorce decree” with the eating disorder and pushing back on him at every turn. In an Academy for Eating Disorders tweetchat (2014) on the topic, Jenni Schaefer tweeted, “Ed could say whatever he wanted. To be in recovery, I had to make the decision to disagree with and disobey him.”

This “externalization” strategy is borrowed from narrative therapy. A key principle of narrative therapy is that the person is not the problem – instead, the problem is the problem. The problem is viewed as something with which the person is in a relationship, not as something that is part of the person. It follows then that the person can separate themselves from the problem and reduce its effects on them.

Family-based treatment (FBT), the leading evidence-based treatment for adolescent eating disorders, adopts narrative therapy’s externalization strategy in dealing with the eating disorder. The perspective taken by FBT clinicians is that the teen must be extricated from the eating disorder’s clutches.

When working with families, the FBT therapist encourages them to treat the eating disorder as an external force that has invaded the teen and hijacked their brain. Some families will even name the illness after a favorite villain such as “Voldemort” or refer to it as “the monster.” The therapist then rallies parents and other family members to unite against this common enemy to help their teen fend it off.

Many patients and family members can relate to this externalization strategy because the teen does appear to transform into a “different person” under the spell of the eating disorder, especially around mealtimes. This externalization allows families to reframe the situation: the teen does not want to restrict their eating—instead, that the eating disorder is an alien force that makes them restrict their eating.

While both Life Without Ed and FBT have given externalization popular traction, research has not definitively answered whether it is a helpful technique. While we do have research showing FBT to be highly effective, FBT includes so many elements it’s possible that it might work without the externalization component. In order to know for sure, we would need special research in the form of dismantling studies that test each individual element of a full treatment—to determine the role of externalization on the overall treatment outcome. There is one recent qualitative paper that studied the process of externalizing the eating disorder.

What are some advantages of externalizing the eating disorder?

  • It offers a convenient and relatable metaphor: “The eating disorder is possessing you.”
  • It can make it easier to call out certain behaviors as problematic even if they do not feel troubling to the patient themselves.
  • Experiencing the eating disorder as an unwelcome invader may help marshal the patient to fight back against it.
  • Redirecting the anger of families and caregivers towards the eating disorder allows them to retain compassion for the patient.
  • It puts everyone on the same team battling a common enemy: the eating disorder.
  • It can help the patient become accountable for their own recovery by learning to rebel against and defy Ed.

Reasons you might not want to externalize the eating disorder

Some professionals worry that giving the eating disorder its own persona gives it too much power and might encourage patients to blame the eating disorder while absolving them of any responsibility for recovery. Some people find externalization too trendy and are put off by it.

According to the qualitative paper by Voswinkel and colleagues (2021), there were mixed perceptions about externalizing by patients interviewed. Some people with eating disorders feel like the eating disorder is a part of them and felt they were not taken seriously or criticized by externalization. Many of the characteristics of patients with eating disorders—such as perfectionism—are actually personality traits that by themselves are not problematic. So by associating these characteristics with an external agent, there is a risk of inadvertently criticizing the patient. People with eating disorders may find the externalization technique dismissive or invalidating of their experience and may become angry when their family members externalize the eating disorder.

So, should you do It?

Clinicians and family members considering externalization should assess the potential risks and benefits of this technique. If you are a person with an eating disorder and this metaphor makes sense to you, you can learn more about the strategy by reading Life Without Ed. If you are a family member of a person with an eating disorder and/or a parent doing FBT, it can also be helpful to consider this as a strategy for talking about the eating disorder with your loved one. Life Without Ed is also good reading for parents and even some teens in recovery.

It is always a good idea to check with the person with the eating disorder about how they perceive externalizing. If you are supporting a person in recovery and they dislike your ascribing the eating disorder its own persona, then you can refrain from talking about it in front of your loved one but still use it as a way to frame your own understanding of the situation.

Eating disorder expert Carolyn Costin, MA, MED, MFT suggests a similar but alternative strategy to externalization: think of the patient as having two aspects of their own self, a “healthy self” and an “eating disorder self.” Eating disorder researcher Kelly Vitousek, Ph.D. offers another option: abandon the metaphor altogether and explain these behaviors to the patient as symptoms of starvation. These alternatives to externalization might be preferable to some people with eating disorders.

Finally, it is important to emphasize that, regardless of the way an eating disorder is framed, behavioral change is critical for recovery. Many of the symptoms and dangers of an eating disorder can be related to nutritional deficits and these symptoms are often improved with proper nutrition and normalization of eating behaviors.

Categories
Grief

Easing Grief Through Connection (Coping Strategy for the Holidays)

By Carolyn Comas, LCSW

Grief can be complicated and a painful process. This holiday season many of us are experiencing the loss of the past year we were supposed to have. For those who have lost someone special this can compound the difficulty of this years’ holiday season. 2020 has not been easy for many of us and finding joy during the holiday season may feel challenging.

Many years ago when I was first starting out as a therapist I was seeing a client for grief counseling. This client shared with me something I had never heard about. They discussed that when you find a dime it is a sign the person you’ve lost is reaching out to you. It is a sign they are with you. This client told me how they had been finding dimes all over the place. That evening, after having met with that client as I was packing up to go home, I looked down by my chair and noticed a dime.

This concept was not lost on me years later after my own mother died. I would find dimes all the time and kept each one that I found. In a grief support group that I was in many of the group members shared about the signs they received from their loved ones. Some talked about coins they found, some said it was a certain type of bird they’d see, and for others a certain song that came on the radio. What I learned was that it did not really matter what the thing was but how that thing  we found kept us connected to the person we love. It brought comfort. It brought peace. It brought healing.

It is okay if you are not spiritual or religious. A sign doesn’t have to signify anything more than a memory or a feeling of connection to that person. Right before Thanksgiving this year my brother sent me a picture of a sweater he saw at a yard sale. It was adorned with carousel horses. My mother was obsessed with and collected all types of carousel horses. In that instant I had goosebumps. “She’s with you,” I said. And he agreed. “I feel it,” he said. “It is nice to think she is here with me.”

Coincidentally, my mom also collected dimes that she found as she believed they were messages from relatives and friends she had lost in her life. I didn’t know this until my dad told me after I shared with him about my new coin collection. Knowing this was something my mom also did made finding a shiny dime even more special. It  really makes me feel like she is with me.

Losing someone you love can be difficult. Finding ways to stay connected through a sign is one way to ease the pain and bring comfort to your aching heart. During this holiday season, if you are struggling with the loss of a loved one think about something that connects you to them. Is there a holiday tradition you use to do together or a song you both sang? Maybe there was a food that was enjoyed together that you could make now. Whatever it may be, know that this could potentially help with healing from the loss you feel during this holiday time or during any time of the year.

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Eating Disorders Evidence-based treatment

Structuring Your Eating Disorder Recovery Environment

 

Recovery is challenging! I am repeatedly moved and impressed by the courage of my patients as they work through recovery from an eating disorder. One strategy that can help support recovery is a careful ​structuring of one’s recovery environment. This applies to adults working individually in treatment as well as to families helping adolescents to recover.

Most evidence-based treatments including cognitive-behavioral therapy (CBT) suggest that patients consider the timing of the start of treatment and potentially postpone it if they anticipate major distractions that will impede recovery. Similarly, it can be helpful when possible to try to minimize challenges.

Recovery looks different for everyone. Some patients are ambivalent about treatment and the changes it will require. Others are eager to be recovered from their eating disorder and just want to get on with life. And many may feel the urge to rush recovery. But I encourage you to “take it slow.”

Recovery 101

As a behaviorist, I like to think of recovery as a set of skills that are learned, developed, and practiced in increasingly challenging environments. Whether you are transitioning to an outpatient level of care or beginning treatment as an outpatient or supporting a teen in recovery at home, those first few months should be treated like “Recovery 101.” This is a training phase in which you are first learning and trying out recovery skills. Your abilities will become more fine-tuned as you practice increasingly difficult skills.

In this phase, it is best to be in a highly structured environment without too many complexities. Most people do best with structure. This is why settings housing large numbers of people tend to be highly structured. (I know – I worked in LA County Jail for 10 years.) This is also why higher levels of care with the sickest patients are highly structured. Structure makes things predictable and reduces anxiety.

In a structured setting, it is easier to follow a routine, such as eating at a regular time, having a familiar meal, and facing fewer distractions. Chaotic and unstructured environments are unpredictable, are more challenging for recovery, and require more advanced and flexible recovery skills.

The Challenge of Environment

In Recovery 101, it is often easiest to start by keeping things simple and predictable. Each element that adds complexity or uncertainty to the environment presents an additional challenge to someone with an eating disorder. Novel situations, different foods, different food venues, and different companions can all bring anxiety to those in early recovery. Any deviation from a routine requires additional skills, so handling each of these should be viewed as a new skill to master.

We can think about this as a ladder with each rung adding new difficulty. At the bottom is generally eating meals at home with support from immediate family. The next rungs might include:

  • Having friends or relatives over for dinner
  • Eating at a close friend’s house
  • Eating at a restaurant where individual entrees are served
  • Eating at a family-style restaurant
  • Eating at a buffet.

Each higher rung on the ladder requires more decisions and thus more skill. Each skill must be practiced.

Take it Slow

Many patients are tempted to climb the ladder quickly, rushing towards the more complicated and challenging situations. This is not advisable when someone is in Recovery 101. Some challenges are better left until recovery skills are stronger, if at all possible. It is easiest to learn skills first in one place and then to practice them in different settings. It is in this way that skills will generalize.

More advanced challenges that may best wait until the basic skills are mastered will vary from individual to individual, but these can include situations such as:

  • Weekend schedules when you have slept late (do you count brunch as breakfast or lunch and how do you handle the rest of the meals when your first meal is 3 hours late?)
  • Cooking for oneself
  • Going to unfamiliar restaurants
  • Eating at a small-plates, buffet, or family-style restaurant
  • Foreign travel to countries where the foods may be entirely unfamiliar

Instead of taking on advanced challenges all at once, consider potential ways to structure the environment during early eating disorder recovery:

  • Having meals planned out for the entire week
  • Eating meals at regular times
  • Regular grocery shopping
  • Having a backup plan (in case you run late or a plan changes)
  • Always carrying snacks (and backup snacks)
  • Planning alternative activities for high-risk times (for many patients that is evenings spent at home. For one patient, that meant going out on evenings her husband would not be home for dinner.)
  • Limiting meals at unfamiliar restaurants
  • Only bringing into the home small quantities of foods on which you have binged
  • Having a support person you can call
  • Structured schedules for every day of the week, including weekends
  • Careful planning ahead (with your team if you have one) for any situation you have not yet practiced

Keep in mind that you may experience setbacks. Sometimes you have to go back down the ladder before going back up again. This is a normal part of recovery.

When recovery is further along, you will be better able to handle more complex and challenging situations. Flexibility will come, but for now, keep it simple.

 

Categories
Eating Disorders Family based treatment

Adjunctive Therapies to FBT: What are the Additional Therapies That May be Added to FBT? And When Should They Be Added?

Photo by Lesly Juarez on Unsplash

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 can also include 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.

Categories
Anxiety

Coping With Anxiety During Anxious Times

John Mark Arnold, Unsplash

by Carolyn Comas, LCSW

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. 

  1. 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. 
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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

 

Categories
Family based treatment Family-Based Therapy

With a Little Help From My Family: Who is FBT For?

 

Photo by Zach Reiner on Unsplash
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.

Sources

Categories
Dieting Weight bias

When Eating Disorder Providers Are Steeped in Diet Culture

Photo by Sarah Gualtieri on Unsplash

“People are concerned about the fact that I’m a therapist and have an eating disorder, and I’m like, ‘You’re concerned about me? I’m concerned about our entire fucking field.’”

— Shira Rose, FoodPsych with Christy Harrison

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.

Defining Recovery

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.

Sources

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.

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