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:

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.