Who Gets Treated for Eating Disorders in Los Angeles?

low cost eating disorder treatment Los Angeles County [image description of the lights outside LAX]This NEDAwareness week, I’ve been thinking a lot about the theme of “Let’s Get Real.” One stubborn myth about eating disorders is that they affect primarily white, upper-middle-class females.

It would take you just one afternoon at my own Los Angeles practice to discover how untrue this is. My clients are all genders, ages, and ethnicities. I accept some private insurance and one public insurance. Among my patients with eating disorders are non-native English speakers, immigrants from low SES backgrounds, and people on public assistance.

The myth that eating disorders affect only the wealthy not only makes it more difficult for patients who don’t meet the stereotype to recognize that they have a problem but affects the entire system of treatment.

Throughout the US, there is a shortage of publicly funded specialized treatment programs for eating disorders. And specialized eating disorder treatment is expensive! The residential treatment complex only serves the economically privileged.

Carolyn Becker, Ph.D. recently brought attention to the presence of eating disorders in food insecure populations. The research on which she collaborated studied adults receiving food at San Antonio area food banks. Those who had hungry children in their households (representing higher levels of food insecurity) had higher levels of binge eating, dietary restraint, weight self-stigma, worry, and overall ED pathology when compared to participants with lower levels of food insecurity

Within Los Angeles County, eating disorders are a covered diagnosis by the Department of Mental Health (DMH). However, according to a DMH district chief, there are no specialized services for eating disorders within the DMH system. I recently led a training on eating disorders at one of the county community mental health centers and a staff member there told me, “Most patients with eating disorders are seen in primary care and none of us are trained specifically in this… What we need is training in evidence-based treatment.”

A clinical staff member at another DMH clinic said, “Honestly, we don’t have a lot of access to resources for people with eating disorders and aren’t equipped to adequately handle serious cases at this clinic. Referrals have always been difficult and there are no reliable referral sources for our patient population. We have really only been able to connect a few of our most severe cases to any treatment at all.”

I searched the Alliance for Eating Disorder Awareness list of Medicare/Medicaid providers and facilities within 50 miles of Los Angeles and came up with only one Medicare provider and no Medicaid providers or facilities.

This blog post was inspired because as a provider for Anthem Medi-Cal, I am receiving calls from county clinics with referrals of other (non-Anthem) Medi-Cal patients with eating disorders that I can’t see. So, when faced with a patient with an eating disorder and no insurance in LA County, what’s a provider to do?  Here’s what I’ve been able to find. If you have other resources, I’d love to hear about them!

Resources

Hospitals

CHLA takes California Medicaid for patients under age 25 needing medical stabilization.

UCLA takes California Medicaid for patients under age 25 needing hospitalization for eating disorders.

General low-fee counseling centers

Southern California Counseling Center

Maple Counseling Center

The Wright Institute

Cal Lutheran Low Fee Counseling Center

Treatment Scholarships

Center for Discovery and Project Heal provide treatment scholarships.

Source

Becker, Carolyn Black, Keesha Middlemass, Brigitte Taylor, Clara Johnson, and Francesca Gomez. 2017. “Food Insecurity and Eating Disorder Pathology.” International Journal of Eating Disorders 50 (9): 1031–40. https://doi.org/10.1002/eat.22735.

 

Thanks to Rosewood Center Santa Monica for help with the referral list.

The Use of Supplemental Shakes in Eating Disorder Recovery

By Lauren Muhlheim, PsyD and Katie Grubiak, RDN

Nutritional supplements in eating disorder recovery - shakes [image description: assortment of supplemental shakes on a table]

Restoring nutritional health is an essential part of recovery from any eating disorder, including anorexia nervosa, bulimia nervosa, and binge eating disorder. The process of nutritional rehabilitation involves eating sufficient food at regular intervals, which reestablishes regular eating patterns and allows the body to recover. In this post, we will discuss the role of supplemental nutritional shakes in eating disorder recovery. In our next post, we will taste-test the different brands and formulations of nutritional shakes on the market, share our opinions, and help you decide which to buy if you are considering using shakes in your or a loved one’s recovery.

Nutritional Rehabilitation

Since many eating disorder patients – even those who are not at low weights – can be malnourished, renourishment is an important step. Ideally it should take place under the guidance of both a medical doctor and a registered dietitian nutritionist (RDN) who can develop a meal plan uniquely suited to the needs of the patient.

Repairing a depleted body can require a very high caloric intake. The recommended rate of weight gain is usually one to two pounds per week – for many of our clients, this translates into required dietary intakes of 3000 to 5000 calories per day. However, it can be unsafe to increase intake to this level immediately due to the risk of refeeding syndrome, a serious condition caused by introducing nutrition to a malnourished person. Calories need to be increased incrementally under a doctor’s supervision and with an RDN’s guidance.

Getting Sufficient Intake

Many people with eating disorders will be able to restore their nutrition entirely with food. And while we always think it is best for patients to eat real food, and that is the ultimate goal, there are many situations in recovery in which the use of supplements can be invaluable. Sometimes, especially early in recovery, it can be hard for patients to get in enough calories via food alone.

During early recovery, when early fullness is a common issue, fortified shakes may be easier both physically and mentally to consume than food. And when getting in enough calories by eating calorically dense foods is too tough, we think the use of supplements is a perfectly good alternative. It is always better than not eating enough.

Supplement Products

Nutritional supplements, made by a number of different companies, contain nutrients in a calorically dense liquid or “shake.” Six to eight ounces of these products typically have between 200 and 350 calories, depending on the brand and formulation. Many large supermarket and drugstore chains sell shakes under their own names, some of which we tested as well. The best-known brands sold commercially in the US are Boost and Ensure, which come in different flavors and are usually sold in plastic bottles. The main lines are dairy based, but there are non-dairy versions known as Boost Breeze and Ensure Clear, which are packaged in juice boxes and may be ordered online. There are formulations with even higher caloric density (e.g. Boost Plus). In hospital settings, these products are used for patients who are unable to eat – following a stroke, for instance – or need extra nutrition. They can also be used in tube feeding.

In recent years, additional companies have emerged to compete with the Boost and Ensure brands. Several companies are developing products emphasizing organic and natural ingredients. Not all of these products are designed with the same goal in mind. Some are in fact marketed to a clientele that is concerned about losing or maintaining weight through low-calorie, “healthy” meal or snack replacement. These products could inadvertently displace foods, beverages, and other liquid supplements that would be much better suited for appropriate weight gain and eating disorder recovery, all the while delivering messages that could reinforce eating disorder thinking. We recommend thinking carefully about your objectives, researching the products you plan to buy, and proceeding with caution.

How to Use Supplements

Supplements taste better chilled than at room temperature. They can be added to a meal in lieu of a lower-calorie beverage, drunk as a standalone snack, or used in the preparation of oatmeal, smoothies, or milkshakes. They can be consumed more quickly than solid foods and can serve for quick convenient nutrition, especially on the go.

They can also be used as replacements. In some eating disorder residential treatment centers, three supplements would be considered the nutritional equivalent of a meal. A patient who refused to eat altogether would be offered three nutritional drinks; one who ate half the meal would be asked to drink two; one who ate most of the meal but didn’t finish would be asked to top off with a single supplement. Parents refeeding children at home can decide whether to offer an alternative meal or liquid replacement when a child refuses to eat or finish a meal or snack.

Instead of bringing home a multitude of varieties, select one supplement brand in perhaps one or two flavors. Limiting unnecessary choice will head off an opportunity for the eating disorder to assert itself in the form of pickiness.

Take Home

The take-home message: supplemental shakes can be a great tool for ensuring adequate nutrition during the refeeding process in eating disorder treatment. Finding the supplement best suited to you or your loved one from among the available options can be overwhelming. Substantial caloric density is your first concern – but finding one that suits your palate is essential to making sure it goes down. Fortunately, the major brands have made a variety of flavors and textures from which you can choose.

We look forward to sharing further recommendations on the nutritional aspects as well as the results of our taste test. We taste-tested many so you don’t have to. Stay tuned as our follow-up blog will delve into further supplement guidance.

Fall 2017 LACPA Eating Disorder SIG Events

Hope Levin, M.D. [image description: photo of Hope Levin]Date:  Wednesday, September 13 at 7:30 PM

Presenter:  Hope Levin, M.D.

Title: Psychopharmacological Treatment of Eating Disorders

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

Bio:  Hope W. Levin, M.D. is a board-certified child, adolescent and adult psychiatrist.  Since 2006, she has worked as a staff psychiatrist at UCLA Counseling and Psychological Services where she serves as the psychiatrist on the eating disorders treatment team.  She co-founded the UCLA Campus-wide Eating Disorders Partnership to collaborate with campus professionals who provide treatment to students with eating disorders.   In addition to her work at UCLA, Dr. Levin is a staff psychiatrist at The Renfrew Center of Los Angeles and maintains a private practice in Santa Monica.

Dr. Levin completed her undergraduate education at Cornell University and medical school at MCP Hahnemann School of Medicine.  She completed general psychiatry residency at University of Pennsylvania where she was Chief Resident, and child and adolescent psychiatry fellowship at the Massachusetts General Hospital/McLean Hospital program, Harvard University where she was also Chief Resident.

Dr. Levin gave this talk previously to our group in March 2012. She will present updated information.

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

Tuesday, October 3 at 7:30 PM

Presenter:  Bobbie Eisenstock, Ph.D.

Title: Media and Body Image: How Media Literacy Can Help Counteract Unrealistic Body Ideals

Description: In our media saturated world, it’s hard to escape the onslaught of messages that tell us how we should look, sell us products to achieve the ideal body, and pressure us to reshape our bodies with promises of happiness and success. How can we protect our self-image from media’s narrow and unrealistic ideals that can make us feel less confident and accepting of our bodies? Research demonstrates that media literacy can help counteract media’s role in normalizing cultural body standards that are naturally unattainable for most and can adversely affect body positivity. This mini-workshop highlights essential media literacy strategies and resources for self-care in the digital age.

Location:  LACPA Office, Encino

Bio:  Bobbie Eisenstock, Ph.D. specializes in the social and psychological effects of media and new interactive technologies on children, teens, and families. She facilitates media literacy workshops for parents, educators, and health practitioners to promote healthy child and adolescent development. A recipient of NEDA’s Westin Family Award for Excellence in Activism and Advocacy, Dr. Eisenstock is on the faculty at Syracuse University in Los Angeles and California State University, Northridge where she directs the Proud2Bme civic engagement project about media literacy and body image. Her students developed NEDA’s Get REAL! Digital and Media Literacy Toolkit and How to Spread Body Positivity in Your Community.

Here is a link to media literacy tips Dr. Eisenstock wrote for NEDA that were posted on its website earlier this month:

https://www.nationaleatingdisorders.org/blog/media-body-image-what-you-need-to-know

LACPA ADDRESS and PARKING INSTRUCTIONS: 6345 Balboa Blvd, Bldg 2, Suite 126, Encino 91316. The buildings are on the south-west corner of Victory and Balboa, and Bldg 2 is the second building from Balboa.  If you come from the Westside, take the 405 to the 101 and exit going north on Balboa to just before Victory (park on the street or in the Sepulveda Basin Sports Complex (6201 Balboa Blvd.) on the west side of Balboa, just south of Victory).  Or take the 405 to Victory (past the 101 if you are coming from the Westside) and exit West onto Victory.  Take it to Balboa and turn left, now heading south.  On your right, you will see the buildings.  The LACPA office is right by the entrance off the parking lot, on the left if you walk in from the parking area.

Parking at The Encino Office Park lot between the hours of 9am – 6:30 pm is restricted to building tenants only.  We can park there in the evening and on weekends, but not 9 – 6:30 weekdays.

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

 

How to Communicate With Your Psychiatrist About Medication

How to Communicate with Your Psychiatrist [image description: doctor holding bottle of medication and writing on clipboard]

In my work with patients who have anxiety and/or depression, I often recommend a consultation with a psychiatrist regarding medication. I believe in the value of psychotherapy; that’s why I became a (non-prescribing) psychologist. However, I find the careful use of psychiatric medications as a helpful aid to psychotherapy. For best results, you must communicate closely and assertively with your psychiatrist about your experience as you try new medications.

It is important to note that I am not a psychiatrist and do not prescribe medication, but I have worked closely alongside psychiatrists in many different settings. I continue to work with patients during the intervals between psychiatry visits. I am intimately familiar with the experiences they have when starting medication. I frequently coach my patients to communicate more with their psychiatrists.

Psychiatric Medicine: an Inexact Science

The selection of an appropriate psychiatric medication is a less exact science than is the choice of medications for other problems. If you have a particular bacterial infection, the specific antibiotic indicated for that infection should work for most people – for example, penicillin for strep throat. However, a medication that works well for one person’s depression may not work for another’s. Unfortunately, we don’t know why that is. Today, there is luckily a large arsenal of medication options from which to choose.  Because some medications work for some and not others, often it takes trial and error to determine which medication works for a particular patient.

Furthermore, the classes of psychiatric medications that are most commonly used for anxiety and mood disorders do not take full effect immediately but rather build up to a therapeutic dose in one’s brain over time. There can be side effects that many people experience before the curative effects kick in. Often patients are started on a lower dose of medication to determine the lowest effective dose as well as to minimize the severity of potential side effects caused by the medication. Further complicating the process, some patients require a higher dosage than others to experience a therapeutic effect.  For example, some may get a benefit from 20 mg of Prozac while others may need 60 mg.

When choosing specific medications, psychiatrists rely on information from drug manufacturers and research trials as well as their own clinical experience of how clients with diagnostic similarities responded to different medications.  These doctors often try to match medication and its side effects with specific symptoms. For example, someone with depression who is very tired may be prescribed an antidepressant that is more energizing, while someone with depression who is more agitated may be prescribed an antidepressant that has a side effect of calming. The side effects often also determine at what time of day the medication should be taken. More activating agents are generally taken in the morning and more sedating medications at night.

Because of the trial-and-error process of matching patients to medications and the lag time it can take to build up to a therapeutic dose, it can take several months to find the right psychiatric medication for a patient. Unfortunately, I too often see clients stop taking medications before they reach a beneficial effect due to some annoying but mild side effect that would have gone away over time.  I have seen patients giving up on medication altogether if the starting dosage of the first medication tried doesn’t help. It is disappointing when this happens because it might have worked.

If a client does not seem to respond to medication, psychiatrists will often first try increasing the dosage to see if a larger dosage produces a positive effect once it has built up, which can take another few weeks. Then if this seems to have no effect, they will usually recommend patients stop or taper the first medication and switch to a different medication, which will take several weeks to ramp up. And then, if necessary, raise that dosage… and so on. Sometimes patients require combinations of different medications, which multiplies the combinations that must be tested.

As you can see, this can be a slow and frustrating process.  Due to the period of time it takes to test the effectiveness of each medication, this can be unavoidable.

What this Means for Patients

When moving to a new medication, it is critical to follow through with the medication plan and communicate closely with your psychiatrist about both the therapeutic effects and any side effects you experience. Your psychiatrist is not a mind-reader.  I have seen many clients who notice no benefit from their medications, wait until the next appointment, which is sometimes months away, to report on a lack of progress. In doing so, they can waste precious time.

Here are some suggestions for working with your psychiatrist and maximizing your chance at more quickly finding the medications(s) and dosages that work for you.

  • Take the medication exactly as your psychiatrist recommends.
  • Keep to the regular appointments requested by your psychiatrist. They typically time these to coincide with the opportune times to gauge whether your medication is working. However, do not hesitate to call them sooner.
  • Take notes on your symptoms and any side effects so you can remember details.
  • Report any severe side effects or suicidal thoughts to your psychiatrist right away (do not wait until the next appointment).
  • Watch for signs of serotonin syndrome, a rare but potentially life-threatening side effect that can occur in response to psychiatric medications. If you experience these symptoms, call your doctor right away or go to the emergency room.
  • Make note of mild side effects (headache, nausea, dry mouth) and try to wait it out. See if the side effects subside after a few days. If not, report to your psychiatrist.
  • Understand how long your psychiatrist has told you it will take to notice a therapeutic effect from the medication. If it takes longer, report to them even if your appointment is still several weeks away. Psychiatrists can sometimes alter a prescription by phone before seeing you again, or they may suggest you come in sooner.

I hope that this information and tips have felt helpful to you. If you are considering medication, it may not be a cure-all, but it can be an incredibly helpful recovery tool. Key is communication!

 

Winter 2017 LACPA Eating Disorders SIG Events

Glenys Oyston, RDN [image description: photo of Glenys Oyston]1.  Date: Thursday, January 26 at 7:30 pm

Speaker: Glenys Oyston, RDN

Title: The Dangers of Dieting

Description: Dieting for weight loss is a cultural norm – everyone does it, has tried it, or has been told to do it at one time or another. But is dieting for weight loss truly beneficial, or is it causing more harm than good? Registered Dietitian Glenys Oyston, discusses how intentional weight loss efforts are actually harmful to the physical, social and psychological well-being of people who engage in them, and what to do about it.

Bio: Glenys Oyston is a registered dietitian, size acceptance activist, eating coach, and blogger who runs Dare To Not Diet, a coaching business for long-timer dieters and weight cyclers who want to break free of food restriction and body dissatisfaction. She coaches people online or by phone through one-on-one and group coaching programs. She is based on Los Angeles, CA. You can find her at www.daretonotdiet.com.

Glenys Oyston, RDN

Dare To Not Diet

Dietitians Unplugged Podcast

@glenysoRD on twitter

Facebook

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

 

abby22. February 10 at 11 am – LACPA Office (in conjunction with Sport and Performance Psychology SIG)

The LACPA Sport & Performance and Eating Disorders SIGs are pleased to announce our jointly held meeting for February, 2017:

Date: Friday, February 10, 2017

Time: 11:00 AM – 12:30 PM

Location: the LACPA Office, Encino

6345 Balboa Blvd. Building 2, Suite 126

Topic: When an Athlete Gets an Eating Disorder

Speaker: Abby McCrea, LMFT

More about our topic and speaker:

Clinical eating disorders cause significant problems for more than 40% of athletes. Subsequently, the subtleties between “good athlete” and “eating disorder” mindsets can become particularly tricky to discern after the onset of an eating disorder. Knowing the risks, possible causes, and how to support athletes with eating problems is essential for developing and sustaining athletic wellbeing. 

This talk is designed to help you:

  1. Explain how and why athletes get eating problems
  2. Recognize the subtle differences between a “good athlete” and an “eating  disorder” mindset
  3. Create ways to support athletes with eating problems

Abby McCrea is a Licensed Marriage and Family Therapist who has a private practice in Sierra Madre, CA. She graduated from Fuller Theological Seminary with a Master’s of Science degree and a clinical focus on the integration between psychology and spirituality. 

With over 13 years of experience in a variety of mental health settings including inner city gang rehab community programs, college counseling centers, and eating disorder residential centers, she brings a depth of understanding, experience, respect, and compassion to her work. In her private practice she specializes and works to empower teens, adults, and families that recovery from an eating disorder is possible.  Additionally, she is passionate about developing research and treatment for athletes with eating problems, and helps clients, families, and coaches in her practice to navigate and manage the delicate balance between life, sport, and recovery.

 Abby speaks nationally on the topics of eating disorders and athletes, eating disorder education, deconstructing social ideals of body image, spirituality and the rituals of eating problems, and identity development among teenagers in life transitions.

Please RSVP and/or direct any questions to Sari Shepphird at drshepp@msn.com

LACPA SIG Meetings are a LACPA member benefit and are open to all LACPA Members. For more information about LACPA Membership, SIG’s and other events, visit the LACPA events calendar: www.lapsych.org

Parking Information:

The LACPA office address is THE ENCINO OFFICE PARK, 6345 Balboa Blvd, Building 2, Suite 126, Encino, CA 91316 – second building from Balboa Blvd., conveniently located near ample free daytime/weekday street parking on Balboa Blvd, south of Victory Blvd.  Both sides of Balboa have all day free parking.  There is also plenty of free parking at the Sepulveda Basin Sports Complex on the west side of Balboa, south of Victory, 6201 Balboa Blvd. (2nd driveway past the Busway). 2-3 minute walk to the office door.  Wherever you park, please check the signs. 

Parking at The Encino Office Park lot between the hours of 9 a.m. – 6:30 p.m. is restricted to building tenants only.  Do not park in the lot at the building. 

 

Checking Our Own Weight Biases as Parents

 

Weight bias parenting [image description: back of teenagers walking on sidewalk]Weight bias is a preference for thinness. In the words of psychologist Ashley Solomon, Psy.D., CEDS, “Weight bias is insidiously interwoven into the fabric of our culture.”

Like many of us, I grew up in a family that possesses a great deal of weight bias. When I gained weight just before puberty my mother put me on diets. My paternal grandfather bribed me to lose weight with the offer of a car. I realize my family members meant well. They stated at the time they were worried I would not be well-liked if I was overweight. At 101 years of age, my maternal grandmother still weighs herself daily and credits the diet she started in high school as the cause of my grandfather falling in love with her.

I have already recounted how I helped my older daughter gain weight when she fell off her weight curve at the age of 12—despite her pediatrician’s misplaced admiration, “You’re just how we all want to be,” (75%ile for height and 25%ile for weight [= thin for your height])” My son and younger daughter gained weight before their growth spurts, which led to that same pediatrician warning me about weight gain and risk of obesity for the two of them. This succinctly illuminates our culture’s weight bias: obesity is a far greater concern than anorexia nervosa.

Now let’s fast-forward to 2 years after the obesity warning for my younger daughter. Nearing the end of her height growth spurt, she has fallen off her weight curve. What is an FBT-trained professional therapist and enlightened mother to do?

She is about 10 pounds below where she should be according to the weight graphs (ignoring the single spurious plot point when I got the obesity warning). She is definitely slender. She does take a medication that could reduce appetite. However, even when she doesn’t take it, she has a small appetite. She does not show any other signs of weight or body concern, eats a range of foods, and is not very active (unlike her older sister when I intervened on her behalf to restore weight).

I notice my admiration for her current shape. I notice the temptation to leave her alone and let her remain on the thin side. After all, my son has gained weight now that he is no longer in high school sports. I notice a stronger urge to react to his food choices than I did when he was thinner. And with some larger relatives in their genetic heritage, I have had the fleeting thought that I would rather keep my daughter thin. WHAT?! I caught my thoughts unconsciously falling into programmed family and societal beliefs that I do not actually agree with on an aware and conscious level.

I examine my feelings and beliefs about what weight gain means for my daughter. I quickly recognized my over-valuing of her slenderness and my own projected anxiety about her potentially being larger. After questioning her pediatrician, who is, not surprisingly, unconcerned, and obtaining a print-out of her growth and weight curves, together we (my daughter and I) settled on adding a daily liquid supplement and mild encouragement to eat more. And, my daughter seems to feel it is a fun challenge.

I do what I ask the families I work with do, which is challenge the bias that thin is better and focus on keeping my daughter on track on her own weight curve, which I know is healthiest for her long term.

November 2016 LACPA Eating Disorder SIG events

The Los Angeles County Psychological Association Eating Disorders SIG will be hosting 2 events in November 2016

Tuesday, November 1 – 7 – 8:30 pm in LACPA Office (Encino) – DBT for Eating Disorders 

Speaker: Charlotte Thomas, LCSW, Program Manager of Portland DBT’s Pathways to Mindful Eating Program

Talk Description: charlotte [image description: photo of Charlotte Thomas]

Dialectical Behavior Therapy (DBT) is an evidence based treatment developed by Marsha M. Linehan, PhD for complex multi-diagnostic individuals with pervasive emotion dysregulation and high risk suicidal behavior. Over the past two and a half decades, research has consistently demonstrated DBT as being effective for patients with a variety of complex problems such eating disorders and substance abuse disorders, where emotion dyscontrol is at the core of the patient’s issues and often interfere with treatment and long-term maintenance of therapeutic progress. This presentation will use a session- to-session birds eye view of the implementation of DBT with complex eating disorders in order to demonstrate use of DBT principles and skills in a concrete, “real world” manner. My hope is to communicate my excitement for DBT, share outcomes commonly generated by DBT, and to generate curiosity among individuals participating in the training.

Goals:

Upon completion of this presentation, participants will:

  • Learn about the first 7 sessions of treatment using a composite client with a complex Eating Disorder
  • Understand the biosocial model of DBT as applied to a composite client
  • Learn about the timing and use of strategies such as dialectics, behavioral chain analysis, and diary cards

Speaker bio:

Charlotte Thomas, LCSW

Charlotte received her master’s degree in Social Science Administration (MSSA) at Case Western Reserve University in Cleveland, OH and trained with Lucene Wisniewski PhD, FAED and Mark Warren MD, FAED for the following 4 years in the evidence based treatment of eating disorders. She is now a licensed clinical social worker in the state of Oregon. Charlotte’s professional interest is in treating eating disorders and associated needs including borderline personality disorder, depression and anxiety. She has experience in private practice mental health settings, providing individual, family, and group services for teens and adults. At Portland DBT Institute, Charlotte is the Program Manager for the Pathways to Mindful Eating program and provides direct service to clients, supervision to staff, and serves on the management board for the clinic helping to inform general clinic policy.

 Friday, November 4 – 12 to 1:30 pm in LACPA Office (Encino) in conjunction with the Couples SIG – Panel Discussion: The Impact of Particular Addictive/Compulsive Behaviors on a Couple’s Relationship, and How to Help – Hoarding, Gambling, and Eating Disorders

3 speakers include:

  1. Regina F. Lark, PhD: Family Stuff
  2. Cristin Runfola, PhD:  Uniting Couples in the Treatment of Eating Disorders.
  3. Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw:  What happens to couples when one partner is a problem gambler?

Speaker bios and talk descriptions below:

Regina F. Lark, PhD: Family Stuff: The impact of compulsive hoarding on relationships with family and friends, creates as much dysfunction as the “stuff” piled around the room. Dealing with it effectively “takes a village” and a strategic plan to calm the relationships between loved ones and the physical environment. Dr. Lark’s presentation will explore the effects of the hoarding disorder and chronic disorganization on the family dynamic, and present strategies for finding clarity amidst the chaos.

Dr. Lark is the owner of A Clear Path: Professional Organizing and Productivity. As a Certified Professional Organizer she specializes in working with people with chronic disorganization, ADHD, and hoarding. She is also a relocation specialist, helping families move or downsize from one home to the next. She is a featured speaker and educator, and is the author Psychic Debris, Crowded Closets: The Relationship between the Stuff in your Head and What’s Under your Bed, Second Edition, (Purple Books, 2014). She serves on the Board of the National Association of Professional Organizers, and is a member of the National Speakers’ Association. She earned a  Ph.D. in History at the University of Southern California.

Cristin Runfola, PhD: Uniting Couples in the Treatment of Eating Disorders. Dr. Runfola will describe recently developed couple-based interventions for eating disorders, including how core cognitive-behavioral couple therapy interventions can be applied and integrated with individual CBT principles for these disorders. Further, she will present data from recent pilot studies conducted with couples affected by anorexia nervosa (UCAN) or binge-eating disorder (UNITE), which yield promising results.

Cristin Runfola, PhD, is a clinical instructor at Stanford University who specializes in the treatment and research of eating disorders. Dr. Runfola’s primary research interest is in developing and testing the efficacy of clinical interventions designed to improve outcome for eating disorders. She underwent extensive training in cognitive-behavioral couples therapy and worked with colleagues at UNC-CH to develop and test manualized protocols for treating anorexia nervosa and binge-eating disorder in a couple context. She is the recipient of various awards, such as the AED Clinician Scholarship Award and NIMH/AED Early Career Investigator Travel Fellowship Award, for her work.

Margaret Altschul, MBA, MA, LMFT: Win, Lose or Draw: What happens to couples when one partner is a problem gambler?

Imagine discovering that your joint bank accounts are gone, your credit cards are charged to the max, and your car is about to be repossessed. This is often the scenario confronting couples when one person is a problem gambler. Problem gambling by one partner brings to a relationship all of the chaos, fear and betrayal of addictions and affairs combined. This presentation will help you gain awareness and understanding about Problem Gambling and learn how you can help couples dealing with the unique challenges this addiction creates.

Margaret Altschul, MBA, MA, is a Licensed Marriage and Family Therapist with a background in education and business. In addition to working with couples, Ms. Altschul applies her training and experience in using EFT and Gottman methods to help adults improve difficult relationships with parents, siblings and people at work. Margaret is authorized by the CA Office of Problem Gambling to provide counseling (at no cost to the client) to people with gambling addiction as well as family members affected by gambling.  She is Director of the Wagner Program at American Jewish University where she trains human services volunteers in basic counseling skills

* LOCATION for both events: LACPA ADDRESS and PARKING INSTRUCTIONS: 6345 Balboa Blvd, Bldg 2, Suite 126, Encino 91316. The buildings are on the south-west corner of Victory and Balboa, and Bldg 2 is the second building from Balboa. If you come from the Westside, take the 405 to the 101 and exit going north on Balboa to just before Victory (park on the street or in the Sepulveda Basin Sports Complex (6201 Balboa Blvd.) on the west side of Balboa, just south of Victory).  Or take the 405 to Victory (past the 101 if you are coming from the Westside) and exit West onto Victory.  Take it to Balboa and turn left, now heading south. On your right, you will see the buildings. Go a bit past the parking lot for the building (we are not allowed to park there during the day), past the Army’s center to the next driveway, which is for the Sepulveda Basin Sports Complex (2nd driveway past the Busway), and park in there. Or park on the street just south of the entrance for the sports complex parking lot. Both sides of Balboa have all day free parking. Allow a 3 – 5 minute walk to the buildings. Walk into the building’s parking area and go to the second building. The LACPA office is right by the entrance off the parking lot, on the left if you walk in from the parking area. Wherever you park, please check the signs

Parking at The Encino Office Park lot between the hours of 9am – 6:30 pm is restricted to building tenants only. We can park there in the evening and on weekends, but not 9 – 6:30 weekdays.

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 

Raising the Bar: Competence in Outpatient Eating Disorder Treatment

Raising the Bar: Competence in Outpatient Eating Disorder Treatment
Lauren and Alli with Charles Portney, MD (who enthusiastically gave us feedback) at ICED 2016.

When my friend and colleague, Alli Spotts-De Lazzer, M.A., MFT, LPCC, CEDS, asked me to join her in writing an article on competence for therapists treating eating disorders, I jumped at the opportunity.

Psychotherapists are ethically bound to treat within their scope of competence. Yet how does a psychotherapist determine if he or she is competent to treat eating disorders, the mental disorders with the highest mortality rates? Alli had searched for a guide or brief resource to help clinicians in training to better understand the basic knowledge recommended for treating eating disorders. To our surprise, few documents existed. Furthermore, we have both often heard that patients and families would like to feel better supported in knowing how to verify the credentials of outpatient eating disorder therapists. Many insurance companies do little vetting in choosing which therapists are listed on their panels as eating disorder treatment providers.

So we decided to create what we hoped would be a helpful document.

Alli and I each have extensive experience treating eating disorders in the outpatient setting. We come from different and complementary backgrounds. I received my original training in the 1990s in an evidence-based research lab under the direction of Terry Wilson, Ph.D, a developer of Cognitive Behavioral Therapy for eating disorders, and I have focused on evidence-based treatments ever since. Alli aligns with an eclectic approach informed by evidence-based concepts, personal experience with eating disorders and eating disorder trainings that range from Continuing Education Units to pre-licensed work at Monte Nido Treatment Center under the leadership of Carolyn Costin.

While we acknowledge that there are many possible paths to becoming a psychotherapist who treats eating disorders, we sought to answer questions including:

  • What set of competencies seem necessary for therapists to know in the outpatient setting?
  • What are many of the unique therapeutic needs of patients with eating disorders including anorexia nervosa, bulimia nervosa, and binge eating disorder?
  • What basic knowledge and training might therapists pursue if they desire to treat eating disorders in the outpatient setting?

In addition to a mental health treatment focus, patients with eating disorders also commonly present with nutritional and medical issues that may need attention. While having well trained, collaborative team members covering medical and nutritional disciplines in a patient’s care is desirable, in a real-world outpatient setting, these team members may not always be available. Psychotherapists working in the outpatient setting who do not have well-established protocols, resources, or collaborators can be particularly vulnerable if/when issues of competence arise.

Eating disorders are psychological disorders that often come with physical, medical, or nutritional consequences and/or complications that call for acute or gradual attention. Psychotherapists, therefore, are recommended to have a basic working knowledge of eating disorder-specific domains extending beyond a psychotherapist’s traditional scope of practice and usual training. Furthermore, each major disorder – anorexia nervosa, bulimia nervosa, and binge eating disorder – can present unique treatment needs and levels of risk.

Our review of the literature incorporating both research and practice guidelines, in conjunction with our own clinical experience in treating eating disorders in the outpatient setting determined that the areas of suggested knowledge generally fell into 5 domains:

  • Assessment and Diagnosis
  • Medical Factors
  • Nutrition and Malnutrition
  • Treatment Strategies
  • Multidisciplinary Collaboration and Levels of Care

Our hope is that the paper will:

  • Help therapists treating eating disorders in the outpatient setting by providing accessible information and resources and assist in potentially improving the experiences of and outcomes for patients;
  • Serve as a useful guide for clinicians desiring to specialize in the treatment of eating disorders;
  • Assist patients and families in feeling more supported by knowledge when seeking treatment providers; and
  • Possibly help to influence insurance companies in the realm of eating disorders.

We are grateful to the following colleagues who gave valuable, substantial feedback on drafts of our paper: Jennifer Thomas, Ph.D.; Charles Portney, M.D.; Stacey Rosenfeld, Ph.D.; Laura Collins; Kristine Vazzano, Ph.D.; Nina Savelle Rocklin, Psy.D; and Elisha Carcieri, Ph.D. We received considerable research assistance from eating disorders informationist, Millie Plotkin. We also thank our additional valued colleagues who provided helpful comments.

After an extensive peer-review process, the paper, “Eating Disorders and Scope of Competence for Outpatient Psychotherapists,” was accepted by and published in the American Psychological Association Journal, Practice Innovations, 2016, Vol. 1, No. 2, 89–104.

therapist competence in eating disorder treatment [image description: photo of the cover of Practice Innovations] therapist competence in eating disorder treatment [image description: photo of the paper]

July 2016 LACPA Eating Disorders SIG – Genetics

image description: photo of Stephanie ZerwasPlease join us:  Monday, July 25 at 7:30 PM

Presenter:  Stephanie Zerwas, Ph.D., Clinical Director of the UNC Center of Excellence for Eating Disorders

Title: It’s All Relative: Eating Disorders and Genetics

Description: For the past 30 years, research has demonstrated that eating disorders run in families due to genetic factors.  Although genetics is not destiny and does not determine who will struggle with an eating disorder, genetic factors can increase the risk of developing these diseases.  In addition, recent developments in molecular genetics have made it increasingly clear that not just one gene increases the risk for eating disorders. Instead, eating disorders are polygenic (e.g., thousands of risk genes when combined together increase risk). Ultimately, molecular genetic approaches will allow us to calculate each individual’s genetic risk for an eating disorder and to personalize treatment based on genetic predisposition.

From a patient perspective, connecting the dots between genetics and environment can be challenging to weave into recovery. It is often difficult to understand that the eating disorder is ‘not your fault,’ but fully comprehending how genetics can play a role in one’s illness can also help alleviate that guilt and shame.

However, integrating research knowledge of genetics into treatment will require sensitivity to how: a) patients understand how genetic risks are expressed, and b) the discussion of genetic risk is woven into clinical practice. This presentation will address the cutting-edge science of eating disorder genetics, how therapists can talk about genetic risk and patient interpretations of genetic research in eating disorders.

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

Bio:  Stephanie Zerwas, PhD is the Clinical Director of the UNC Center of Excellence for Eating Disorders.  A clinical and developmental psychologist, Dr. Zerwas works as a family-based therapist and as a researcher studying the genetics of eating disorders. She is a member of the Psychiatric Genomics Consortium – Anorexia Nervosa Working Group. In addition, Dr. Zerwas studies the factors that predict recovery from anorexia nervosa, eating disorders during pregnancy and postpartum, and how technology can assist eating disorder treatment and research.  She is a TEDx speaker and passionate about translating eating disorders science to patients and the public.

RSVP to:  drmuhlheim@gmail.com

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

Five Reasons Parents Should be Included in the Treatment of Children and Adolescents With Eating Disorders

I had the honor of presenting a workshop yesterday along with Therese Waterhous, PhD/RDN, CEDRD. and Lisa LaBorde, Outreach Director for Families Empowered and Supporting Treatment of Eating Disorders (FEAST) at the IAEDP Symposium 2016. Our workshop was entitled, From “Worst Attendants” to Partners in Recovery: Empowering Parents as Agents of Change for Children and Adolescents with Eating Disorders.

image description: photo of Therese Waterhous, Lisa LaBorde, and Lauren Muhlheim

A growing body of scientific research demonstrates that parents and caregivers can be a powerful support for a child in recovery from an eating disorder. This model of care is a radical shift from the traditional individually focused therapeutic approach and requires significant changes in how patients and families are treated within a clinical practice.

During my section of the presentation, I presented Five Reasons to Include Parents in treatment for youngsters with eating disorders. I share them here:

  1. The reason to exclude parents was based on theories that have now been debunked.

In the late 1800s Gull suggested that families were “the worst attendants” for their children with anorexia nervosa, and this set the tone for many years. More recent perpetrators of this viewpoint were Hilda Bruch and Salvador Minuchin. In the historical treatment of eating disorders, parents were blamed and the children were taken away to be fixed by professionals. When ultimately sent back home, parents were told, “Step back,” “Don’t get into a battle for independence, “ and “Don’t be the food police.”

These practices were based on early theoretical models for eating disorders that have not been supported by empirical studies. Research has not been able to identify any particular family pattern that contributes to a child’s eating disorder.

  1. Best practices now state to include parents (and not blame them).

As the following clinical guidelines demonstrate, it is no longer the appropriate standard of care to exclude families from treatment.

The Academy for Eating Disorders’ position paper on The Role of the Family in Eating Disorders:

  • The AED stands firmly against any model of eating disorders in which family influences are seen as the primary cause of eating disorders, condemns statements that blame families for their child’s illness, and recommends that families be included in the treatment of younger patients, unless this is clearly ill advised on clinical grounds. 

The Nine Truths About Eating Disorders consensus document, produced in collaboration with Dr. Cynthia Bulik, PhD, FAED states:

  • Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

The American Psychiatric Association (APA) Guidelines for Eating Disorders also advises:

  • For children and adolescents with anorexia nervosa, family involvement and treatment are essential. For older patients, family assessment and involvement may be useful and should be considered on a case-by-case basis. (p.12)
  1. Research shows better and faster results when parents are included in mental health treatment for their children.

Randomized controlled trials of adolescents with anorexia nervosa and bulimia nervosa show that adolescents who receive family-based treatment, in which parents play a central role, achieve higher rates of recovery and recover faster than adolescents who receive individual adolescent focused therapy. This result is consistent with findings for other psychological disorders, including Obsessive-Compulsive Disorder (improved outcome is found when families are included in treatment) and schizophrenia (a large scale study found greater improvement when treatment included family education and support as part of more comprehensive care).

  1. Parents are often good allies in fighting eating disorders.

On the one hand, patients with eating disorders (and especially younger patients) are often significantly impacted by malnutrition. Research shows they commonly have a decrease in brain grey matter, cognitive deficits and anosognosia—a lack of awareness that they are ill. Recovering on one’s own is commonly difficult for an adolescent whose brain is not fully developed and may lack the cognitive ability to challenge negative thoughts, change behavior patterns, and resist urges. Furthermore, they commonly lack the independence adult clients have to purchase and prepare their own food.

On the other hand, parents are there to take care of their children. They can do the heavy lifting. They can be authoritative and require children to eat. It can be difficult for a therapist to develop rapport with a reluctant and resistant adolescent; it is much easier for a therapist to develop a therapeutic alliance with the parents who do want their child to recover. In situations where there are multiple treatment providers, parents can help with the communication between team members as they will likely be seeing them all. Lastly, parents typically buy the food for the household so they have the ability to execute the meal plan.

Eating disorders often take years, not months, to fully resolve. There will rarely be a scenario in which a patient leaves home for a residential setting and comes home “cured.” The reality is that any treatment is only the first stop on the road to recovery–full recovery takes sustained full nutrition and cessation of behaviors for an extended time period and the family, in many cases, can help that happen. So whatever treatment model is used, FBT principles and training are vitally important for families.

  1. Parents are powerful.

In the past, mental health treatment was primarily private; the internet has changed that. Parent support and activist groups such as FEAST, Eating Disorder Parent Support (EDPS), March Against Eating Disorders, and International Eating Disorder Action,have connected parents, given them access to scientific information that was not available to parents pre-internet, and given them the tools to organize. Social media has increased the pace of this information. Parents have access to evidence-based information and are demanding treatment that aligns with it. If they are shut out from treatment, they will hear from other parents that this is problematic. They may change providers if they are dissatisfied with the treatment their child is receiving

There is no greater love than the love of a parent for their child. To work with parents and empower them to help their children get well is one of the most rewarding aspects of my work. Family-Based Treatment is at the forefront of treatments that center the role of parents. Learn more about our approach, Family-Based Treatment.