Thursday, December 5, 2013

Weighing versus Intuitive Eating

Often, weighing yourself is a big part of having an eating disorder. Sometimes many, many times a day. That number on the scale, and the one inside your pants, comes to drive how you feel, what you do, how you eat, and how you view yourself. Suddenly, that number on the scale seems to be driving everything.

But, it feels reassuring. It feels comforting to know what is happening with that number (though, let's be honest, only as long as it is not going up!). Your eating disorder is reassured by that illusion of control. So, it is hard to let go of the behavior. I have had numerous new patients argue with me that seeing their weight helps, not hurts--mostly because the client is too scared to not know the number. Being weighed by us is often a significant area of stress, and sometimes conflict.

And, of course, this is another area of great debate in the field. Should we show weights or hide weights. Do they hurt, or do they help? And how do you know from patient to patient?

At UCED, we do blind weights, for those with whom we need to do weights. Why? Because we also teach intuitive eating. And, weighing yourself and becoming an intuitive eater are pretty much diametrically opposed (which is why we do not weigh people who are practicing intuitive eating). But why is it so unlikely to work if you both weigh yourself and try to become an intuitive eater? Intuitive eating is based on trusting your body and learning to follow your body's cues. The goal is to eat when you are hungry, stop when you are full, and eat a variety of foods.

Enter, the scale. You jump on that "wonderful" little thing and it gives you a number. What if that number is higher than you want it to be? Chances are you will automatically change your eating behavior to compensate. You will restrict the amount you are eating, or the range of foods you allow yourself. And, as we have covered before, that restricting has a very high chance of then leading you to overeat. And the cycle of disordered eating continues. You are quickly taken right away from from following your body's cues, and intuitive eating has gone out the window.

So, what do we recommend? I highly recommend getting rid of your scale in the most glorious fashion possible. I have had patients confirm that scales don't bounce when dropped from significant heights and they do shatter when hit with another solid object! Send your scale out with a bang! Or, give it to a loved one so they can make it disappear. Take it to your therapist/dietitian/doctor. Or, put it in the garbage yourself, and wave good-bye.

Think of the freedom that can come when your mood and behavior is not dictated by a number on a scale. We are all much more than a number, and the number says absolutely nothing about us as people.

Monday, December 2, 2013

UCED's Treatment Approach for Adolescents with Eating Disorders

For the past couple years, there has been a lot of research going into, and professional debate regarding, the appropriate treatment of adolescents with eating disorders. Eating disorder treatment, and the mental health field in general, is a hard field when it comes to finding concrete answers as to what is the best approach for treatment. In general, the focus is on identifying empirically/research supported treatments, and then using clinical judgement and skill to identify what will work best for a particular individual.

Recently, most of the focus in treatment of adolescents has been on Family Based Treatment (FBT), which is also known as Maudsley Method. Lock and LeGrange are the main forces behind FBT here in the US, and there are ongoing trials continuing to assess this treatment approach. The mindset behind the approach is keeping adolescents at home, rather than sending them to inpatient/residential treatment centers. Treatment centers certainly have their benefits and are needed in some cases, but our stance here at UCED is that every adolescent (and adult) should first be able to try outpatient treatment at home, prior to being sent to an inpatient/residential program.

One of the major tenets of FBT is the idea that parents know how to feed their children. If you go back in the history of the understanding of EDs, unfortunately, you will find a lot of blame on parents and families. The field as a whole no longer has this attitude towards families, but some long-held beliefs are hard to get past. Fortunately, FBT has shown that many adolescents can get better at home, with their families. However, as with any therapeutic approach, one size does not fit all.

Our approach with adolescents is to first give the teenager a chance to show they have the motivation to get better on their own. So, first we give them the opportunity to make healthy choices regarding food, with the support of their parents. A surprising number of teenagers actually will choose to get better without invasive intervention--a testament to the maturity of these young men and women, and their awareness that the ED is not serving them well. Because adolescents live at home and are supported primarily by their parents, in addition to friends, we involve parents in therapy frequently; typically every other session, although some teenagers choose to have their parents involved in every session. This approach, which teenagers typically are not thrilled to hear about initially, allows us to avoid the risk of the ED "splitting" the treatment team and the parents. Fortunately, most teenagers quickly realize family therapy isn't THAT BAD and come to accept it pretty quickly. (Sometimes parents end up disliking it more than the teenagers!)

If, with this structure, the teen remains unable to do what he/she needs to do in terms of food and activity, we transition to more of an FBT approach, which provides the parents with much more say in what the child is eating and doing. This is a tough transition for some teenagers, as the last thing they want is for parents to tell them what to do! However, on the flip side, this can provide motivation to do what they need to with food, so they can regain some control. This approach is often difficult for parents because they find themselves feeling pulled to "go easy" on their teen, which unintentionally ends up as negotiating with the eating disorder and allowing it to get away with ED behaviors. Therefore, parents need a lot of support in supporting their teens during this phase of treatment. Fortunately, there are a number of resources for parents in this situation; some include:

  • aroundthedinnertable.org
  • maudsleyparents.org
  • feast-ed.org
Finally, there are some teenagers whose ED is so deeply entrenched that inpatient/residential treatment is what is needed. Fortunately, there are very solid adolescent treatment programs in the US, many of which use the FBT approach. At that point, we will help facilitate the teen's admission to a treatment program, and provide ongoing support for the family, as there is still work to be done to make for a successful transition back home.

It is terrifying to have a teenager with an eating disorder. Parents spend a lot of time blaming themselves and trying to figure out what they did wrong. Eating disorders are not so simple as to be caused by one thing, including parents and families. But, by working together, the teen and parents can rid the family of the eating disorder, and strengthen their bonds. 

Tuesday, November 26, 2013

Using Intuitive Eating During the Holidays


--by Nicole Holt, RD

The holiday season can be a difficult time of the year for those who struggle with an eating disorder. It is a time of the year where family gatherings, work parties, and holiday activities are often centered on food and impressing others. On the other hand, the holidays can be an opportunity to stand up to your eating disorder and practice intuitive eating skills. Let’s go over some intuitive eating concepts to help you feel confident as we enter the holiday season.

As an Intuitive Eater, you know:
  • ·      If you restrict your intake throughout the day to compensate for a dinner party, you are most likely going to be overly hungry at the party and eat until uncomfortably full.

  • ·      If you eat past fullness, do not panic. The feeling of fullness will likely pass in less than a half hour. In the meantime, you can distract yourself with a conversation about gratitude, or a holiday song!

  • ·      It is your right to honor your fullness and say "no thank you" to seconds or dessert.

  • ·      If you want seconds, you are free to eat them without feeling guilt, judgment or the need to exercise, or purge, to compensate.

  • ·      All foods fit in a healthy diet, including stuffing, pie, and whatever else our society labels as unhealthy!

  • ·      You are the expert on your body.  Nobody can feel your hunger and fullness but you.


Being an intuitive eater doesn’t mean you are perfect. Sometimes it means that you eat more because it tastes good. It can also mean creating an escape from an eating situation because you are overwhelmed and need a minute to yourself. Whatever it may be, have faith in your intuitive eating skills this holiday season.

Thursday, November 21, 2013

Equine Therapy in Eating Disorder Treatment

My interest in animal-assisted therapy began with the puppy-love-of-my-life, Shadow. I became the very honored owner of Shadow, a rescued shiba inu, in May 1999. Although we did not know her history, it quickly became evident she was likely neglected, and potentially abused. I was in graduate school at the time, and Shadow was my first dog. She quickly became the (puppy) love of my life and our bond grew to be very strong. During graduate school, once a semester, she was seen in class, helping me to teach learning theory principles to my Intro to Psych students. 

Upon completion of graduate school, honestly, I just wanted to take Shadow to work with me. So, I got her certified as a therapy dog, and over the next few years, she went to work with me at two different treatment centers. I quickly realized that her own skittishness and avoidance of contact was a wonderful conduit for helping those who had experienced trauma to see that their reactions were normal. Shadow never was the cuddly dog one might expect of a therapy animal; many of my clients never really got that physically close to her. But, I was repeatedly told of the major impact that she had, and since have been surprised to hear of the number of past clients who chose to get a shiba inu in adulthood. 

At times in my career, I have been exposed to equine assisted therapy. And I always saw the potential, and was strongly impacted by the ways it could be beneficial for those with eating disorders. I have begun a training program for a specific type of equine assisted therapy, called Gestalt Equine Psychotherapy, and I have a new partner in crime, Daisy (or if we are feeling particularly elaborate: Miss Daisy Mae). I thought I'd talk some about the connections I see between equine therapy and eating disorder treatment, and I'd love to hear others' thoughts about this. Reality is that equine assisted therapy is not a highly researched field. There's not a lot of concrete data to back it, but those who do it know intuitively it's effectiveness, and those who experience it are often blown away by how powerful it is. So, why equine assisted therapy in eating disorder treatment? These are my initial thoughts:

1. In my opinion, "the best" equine assisted therapy is about the relationship with the horse. It is not using the horse as a "tool," but instead as a co-therapist. Eating disorders have the impact of disconnection, from oneself and from others. For various reasons, human relationships can become threatening, yet that with an animal can be safe. The horse as co-therapist can help facilitate reconnection: with one's emotions, with one's physical body, with relationships in general, and with others in the client's life. When one has an eating disorder, they often cut themselves off from the head down. The body is often ignored at best, and rejected at worst. Well, imagine trying to engage on the ground with a very large animal, without being present in one's body. To take it one step further, imagine trying to sit upon a horse, or ride a horse, without being connected. As you can imagine, these things would be very difficult, so interaction with a horse can challenge that disconnection in very real, and powerful, ways.

2. Trust: Let's face it; horses are at least 900 pounds, and taller than us. They physically present a challenge to trust. But they will quickly illustrate the desire and motivation to trust us as humans. And that can be so powerful to those who have learned to distrust others.


3. Mirroring: One of the most powerful things I see in horses is their ability to mirror us as humans. They will physically represent many of our emotions, when they are connected to us. And they often seem to have an uncanny ability to present what we are dealing with. For example, I just recently watched a horse literally push around someone who was talking about feeling pushed around in her life. They present an opportunity to face a challenge that is too scary to face with adults. 


4. Presence: This is very similar to the connection piece. But those with eating disorders, almost without fail, have high anxiety. They are often lost in their thoughts, overwhelmed by their fears and worries. Being in the presence of a horse challenges that. If you don't engage with a horse, and be present with them, they will literally turn and walk away. But, if the client become present, the horse will engage. This can be a powerful illustration of what happens in human relationships in the life of someone with an eating disorder.

5. Communication: Those with EDs often become silent, not saying what they are thinking and feeling. A horse, or a dog, can present a safe environment for beginning to open up again, and then a safe partner for beginning to talk to people whom the client might find more threatening.

I am really interested to hear what thoughts others might have regarding the overlap between equine assisted psychotherapy and eating disorder treatment! This work is being done in inpatient and residential settings a lot, but perhaps is less common outpatient. I am excited to see this area of eating disorder treatment continue to expand.


Thursday, October 3, 2013

Insurance Coverage for Eating Disorders--a year later

Imagine my surprise when I looked back at the history of posts, and noticed I posted on October 4, 2012, about insurance coverage for eating disorder treatment. I then looked down at my watch and confirmed, it is in fact October 3, 2013 today. Very strange.

What I'm sad to report is that this remains a very real battle for individuals needing eating disorder treatment. There is movement on the national and state level to advocate for better coverage, but the progress is slow. I wanted to share a recent story to highlight this battle, and then provide some ideas of things you can do.

Over the past few months, a family has been battling their teenager's eating disorder at home. This teen had sought inpatient/residential treatment previously, and was discharged as soon as his benefits were exhausted. The parents could not afford the high costs of ongoing residential care on their own, which is true for most families. The only likely outcome came to fruition. The teenager relapsed and I met the family a few weeks later. The teen was admitted to the hospital, which began to fight the insurance company for ongoing benefits. I have never seen a hospital phrase their concerns so strongly, including repeatedly referring to the teen's situation as "life-threatening." The hospital went through many appeals, yet insurance continued to deny coverage for anything other than outpatient care. This was a teenager who was not medically stable to be in outpatient care, and, without a doubt, met criteria for inpatient. But, in the end insurance won, and the teen and family were discharged and returned for outpatient treatment.

This situation highlights a number of concerns about the role of insurance companies in eating disorder treatment. In this case, an insurance reviewer determined the care that this very sick teenager could receive. Of course, we can all make the argument that in the end it was the parents' decision, but is it really a decision, for the average family, when their option is to pay $30,000+/month, out of pocket, for inpatient treatment? Certainly, the insurance company made the argument over and over that it was "not their fault." "The benefit is exhausted," they proclaimed. Yet, every insurance company has the option of providing additional coverage when the need arises, if they choose. Some will choose to do so; clearly, others will not.

So, what can you do when you find yourself trying to battle an insurance company, or insurance policies in general:

  1. Lisa Kantor, of Kantor and Kantor, is an attorney in California that is well-loved within the eating disorder community. She is taking on insurance companies and fighting for appropriate coverage for eating disorder patients. So, consider contacting her to see if she can help with your case.
  2. Appeal, appeal, appeal. You shouldn't HAVE TO fight this hard, but reality is that if you battle the insurance company enough, they often will eventually listen. The squeaky wheel, and all that.
  3. If the eating disorder has resulted in medical complications, make sure hospitals and treatment centers are billing under medical codes, when possible. So, rather than billing for anorexia, they would bill for the medical sequelae: hypothermia, bradycardia, orthostatic hypotension. Even if the treatment has already been billed under an eating disorder, ask them to correct the bill, providing the medical diagnoses instead. This will mean your medical benefits are used, not mental health.
  4. Research the mental health parity laws in your state and make sure the insurance company is in compliance with these.
  5. Contact your legislators and make them aware of the need to address appropriate coverage for eating disorders. Ask them to review legislation in other states, or at the national level, and propose similar legislation in your state. 
  6. Ask the insurance company to flex your benefits. An example might be that you have 10 inpatient days, which generally can be flexed to greater partial (PHP/day treatment) days, and even more additional outpatient days.
  7. Ask your physician to provide a referral for dietitians and therapists, making it clear the physicians sees these services as paramount to the patient's care.
I'm sure there are other ideas that have worked for others. Please, if you have had success battling an insurance company, share what has worked for you.

Honor Your Hunger

by: Nicole Holt, RD, CD


Hunger has helped mankind survive since the beginning of time. Without a primal drive to seek food in times of need, the human species would have ceased to exist. This is why statements like, “I am an awful person because I overate,” or “I ate this food because I don’t have any control,” are misguided and unhelpful. 

It may come as a surprise, but the body doesn’t respond to shoulds and food rules. Our body has a process that is remarkably efficient when we let it do its job without interfering.

During the day your body gauges a number of things including blood sugar levels, hormone levels, and stretch receptors in the stomach. If levels vary from acceptable, and the stomach is empty, your brain triggers the hunger response.  If we refuse to eat intuitively, by either under eating or ignoring hunger signals, our digestive system interprets the lack of nutrition as starvation. When our body realizes the energy deficit, it fights back by causing extreme hunger, anxiety, dizziness, crankiness, etc to protect against the effects of malnutrition. We may interpret these signals as lack of willpower and drive, when in reality our organs are working hard to combat starvation.

The authors of Intuitive Eating have this to say about honoring your hunger:

“Keep your body fed biologically with adequate energy and carbohydrates. Otherwise, you can trigger a primal drive to overeat. Once you reach the moment of excessive hunger, all intentions of moderate, conscious eating are fleeting and irrelevant. Learning to honor this first biological signal sets the stage for rebuilding trust with yourself and food”.

In other words, to avoid chaotic eating you must do something that feels completely counter intuitive--eat!

Some helpful tools for preventing hunger include:

  1. Checking in with yourself every couple of hours to gauge your hunger and then       acting upon it if needed
  2. Combining carbohydrates and protein sources for energy and lasting satiety
  3. Planning meals and snacks ahead of time
  4. Keeping snacks on hand in case of hunger
For most people, the most distressing eating disorder behavior is overeating or bingeing. Hopefully this information helps to clarify the role under eating or dieting plays in leading to these behaviors and helps motivate you to honor your hunger!




Wednesday, July 31, 2013

The Job of a Therapist

A therapist's job is an odd one. In fact, my job is officially to work myself out of a job. Weird, huh? But true. My job is to support people in "getting better," however that is defined, and then watch them walk away. When I started this blog, it was called Within Four Walls, because part of what I wanted to be able to communicate was the power, and for me, joy, of working with people with eating disorders. A couple years ago, I was at a local gathering of people who treated or wanted to treat eating disorders, and I was appalled when I heard a therapist state, "Oh, nobody with an eating disorder ever gets better anyway." I had to bite back my desire to tell her to never, ever see another eating disorder patient. But, that is an a common misconception; that eating disorders are generally untreatable. So not true.

Recently, I had a final session with a woman who I have been working with for years. Obviously, I don't want to disclose details about this woman, but also want to say enough for you, the reader, to understand why the statement that people with eating disorders don't get better is so wrong. When I met this woman, she was a shell of a person, in every way.

Today, she left to move to another place to start a graduate program. And, when you hang out with someone every week, or so, for a few years, you lose track of all the changes that happen. It's not until you look back at where things started that it really strikes you, the therapist, just how much changed. I'm sure if anyone were going to, this woman fit the profile of the person who would "never get better." The severity of the illness and it's impact on her physiology, the overall impairment in functioning in her life; there was a lot going against her. When I look back, I see that it didn't look good all those years ago. But, years passed, and in reality, she has been recovered from her eating disorder for years. It has not been the focus on her therapy work for a long time and many situations have shown she truly is in recovery. Therapy became about life and rebuilding, and she did.

In the final session, she tried to give me the primary responsibility for "getting her better." Nope, that wasn't going to happen! It wasn't me. So, what was it? Well, first it was that she wanted to get better. She started the process, she continued the process, she hung in there through hairy moments and good. She drove the process. If you really think about it, what is eating disorder treatment? Sure, to a certain extent we help people "re-learn how to eat." But, really, everyone KNOWS how to eat. We don't have super Jedi mind tricks that somehow make someone eat again.

So, what is it that we do? If you look at psychology, and therapy in general, I'd hate to even try to count the number of approaches that us therapists can be trained in. There's about every cute little combination of letters in the book, all labeling some therapeutic approach that is destined to be the NEXT, BEST THING!

But a couple years ago, when I was panicking about a patient and whether I was doing things "right," and was told by some clinicians that I was doing things wrong, another clinician pointed out the research that basically says that we as therapists can do almost anything, within reason, and as long as we believe it works, and then our patients believe it works; well, it tends to work.

So, you take all those therapy approaches....CBT, IPT, DBT, ACT, ABCDEFG (that's not really one), and they all work, really. But what I believe works, what I believe therapy offers people, is a relationship. That's what therapy is, and that's what we, as people, need (except, as I always tell my clients, there is this guy that lives in a cave outside of Nederland, CO...or at least he did when I was in grad school...and there are a few people like him that seem to not need relationships....but those folks are rare). So, that's what I offered to this woman. I did not "make her better." I gave her a relationship, and she chose to use that relationship to change her life. And, in my experience, the change that comes from the power of the relationship is long-standing. So, I don't worry that she will return to her eating disorder. I truly believe she is recovered. And that puts a huge smile on my face, knowing where things started. She chose her life over her eating disorder.

So, I was reminded by this patient the true power of what happens Within these, and all other, Four Walls.