"Not a coping skills kinda therapist"

Recently, I've been hearing more than ever before the phrase, "coping skills" as it relates to therapy. And each time, I have the same basic response, which is, "I'm not a coping skills kinda therapist." And of course I explain what I mean by that, but I thought I'd comment on it here too.

Of course, to a certain extent, "coping skills" can just be a buzz word (phrase?) that takes off, which I assume has happened lately. And, of course, all therapy does include increasing coping skills in one way or another. But, when I say, "I'm not a coping skills kinda therapist," I mean that I'm not a therapist whose focus is teaching this or that coping skill. I guess my thought process is that, essentially, one can read a book and be taught coping skills, so why would I be charging people to do the same?

That probably means I should find some really good coping skills books, but, I promise, I tried for years to read self-help books so I could recommend them, and I just cannot. I mean, do you want to read about your work during your free time? No, me neither...

So, if I'm not a coping skills kinda therapist, what kinda therapist am I? Well, in graduate school, we had to "defend" our therapeutic approach prior to them letting us go out on internship. I had a firmly held belief that Interpersonal Therapy and Cognitive Behavioral Therapy worked together in eating disorder treatment. Now, I was warned to never try to defend this at the time. Butttttt, I'm stubborn, and it genuinely was my approach to therapy, so I did exactly that. And, against all odds, I passed. Shortly thereafter, it became more mainstream to see these two approaches, previously seen as somewhat opposite, as blending well. Whew!

It's been a long time since graduate school, and I work very hard to not speak in psychobabble, so here's a very short blurb of how I see IPT and CBT going hand in hand in ED treatment: Interpersonal therapy basically looks had how relationships have impacted a person (the very, very short version) and sees healing as existing in relationship. CBT challenges your thoughts and behaviors (pretty obvious how that applies to EDs). I believe that our experiences in our relationships impact our thoughts and behaviors. (Believe me, I had to say more than that perfectly clear sentence to defend it a the time!!) And, I believe relationships are what have the power to provide healing.

So, early in treatment, I am more CBT. The behaviors must change for reasons thoroughly discussed in other posts. But, the other focus is building a relationship where what I say matters, and a relationship in which healing can occur. And that is anything but "coping skills kinda therapy." I can teach a coping skill without any real relationship; again, a book can teach a coping skill. But, what I hope to be able to do is understand someone on a deep enough level that I can help them to make lasting change.

(On that note, if you ever want what I believe to be a massive challenge....try writing what you hope to accomplish as a therapist without sounding like a fluffy...well...ball of fluff. It's not easy to put into words.) 

I will tack on...I do also believe both IPT and CBT help someone work through PTSD also, though believe it is MUCH MORE about the IPT and also body-focused therapies advocated for by Bessel van der Kolk and Peter Levine. 

Social Media Often Seems Socially Acceptable Bullying

 My dressage coach yesterday told another rider and myself to be sure to watch a particular ride from an international dressage show. I had been following scores, but had not watched any specific rides, because....as awful as this is to say.....dressage is not the most fascinating thing to watch, and I have watched A LOT of Grand Prix dressage by now. 

So, I went and watched, and it was fantastic. But, as I explained to my coach today, these major events bring up two sides for me. One, watching the experts at riding can be phenomenal learning, whether it's what "to do" or what "not to do." But on the other hand, each major events brings the "armchair equestrians" out in droves, and, boy, are they brutal online.

I'm an amateur equestrian, which I think might well be synonymous with being an insecure equestrian. This sport is like none other; because you do not have full say over what is going on, and perhaps could argue that the 1000lb animal might truly have the most say, you literally never truly know "how to do" the sport; we are all truly always learning. And, it's a sport we can only practice so much each day; our partners can only tolerate 30-60 minutes per day, so there's no practicing for hours like there is in other sports. And, lastly, what an expensive sport! So, us amateurs work too; I am lucky to ride two horses per day. Many only ride one. Put all that together, and I would argue it's very hard to feel confident, and many days, competent. 

So, I read the things that people say about the riders at the top....topics include to what extent they are abusing the horse, how awful they are as riders, how awful their training methods are purported to be, how the judges are not looking out for the horse, which leads to arguments that dressage is abusive and should not occur. I just watched a video that proclaimed that this one lesson by this one trainer for this one rider was evidence of "the downfall of dressage." Sheesh!! For one who loves her horses, this leads to a major internal "aaaack," as I then wonder, "Wait, am I like that? Do I do that? Do I do that and not know I do that? Is the sport I love actually abuse???"

And, when people stand up to the bullies, they are told, "So, you don't care about the welfare of the horse?!" Oh boy. Okay. Well. Essentially, it never ends. And yet it's so easy to get sucked into reading the threads, in hopes that eventually it will all make sense.

That has led me to assume those that rise to the top of this sport must be very brave individuals, as they are literally signing themselves up to be judged in a public forum. And not just by the judges they pay to ride in front of, but everyone with various agendas on social media. And, to be fair, I think this applies to any one of us, at this point, in a public role, because the bottom line is, if you put a human behind a screen, particularly without their name attached to their words, that human might very well be brutal.

Before social media, word didn't spread like it does now. There were not venues for trashing other people, building up into a frenzy at times. Yes, as a rider, I do observe those at the top and have my own opinions on what I like to see and what I do not, what I want to emulate and what I do not. I had that same experience with my first experience in the eating disorder field too; I learned what I'd never do in addition to things I continue to put to practice to this day. But it's hard for me to imagine sharing my views other than to ask my coach if what I'm thinking has any validity at all! But, whew, some people really get into it online, for sure.

But, here, I am talking about adults. Now, imagine it's a teenager, or a pre-teen, trying to figure out how to navigate what is being said online. They all think they can handle it, and I assume most will never experience the worst that is out there. But, for those who do? Sheesh, if reading strangers' reactions to the top riders can actually make me ponder whether riding my horse is abuse...well...I guess I just have to assume that a teenager can easily end up questioning themselves too. 

My coach told me today, as I explained all of this, "You have to not read that stuff," and I guess I believe that might just well apply to the vast majority of social media. Humans are brutal when they are behind a screen, and I will continue to encourage everyone to go back to the "good ol' days" where interactions are face-to-face, not keyboard to keyboard.

Understanding the new link between social media and mental health

 I have been following the general public's reactions to this news about social media and its impact on eating disorders and mental health. And what I am seeing is that the real point is not truly being understood. For example, read the comments on the KSL article posted 12/9 on the topic.

Yes, it's well known that social media of any type has a questionable impact on mental health. Some research shows that social media can have a positive impact. Examples that I see of this in my practice is patients reporting interactions on pages designed to be support groups, or promote positive body image, or sharing podcasts that support therapy goals. These are clearly all positive places on social media. And, research backs this up. The study that I focused on, which looked at a number of studies (what is called a meta-analysis) showed that those who actively engage in social media, defined as talking to others on Messenger, for instance generally have a positive experience with social media. But those who "passively" use social media tend to have a negative experience. Examples of this are simply looking at others' content, perhaps hitting "like," or maybe commenting, but not directly communicating with others, tend to have more negative experiences. So, that covers what we have known for a while about social media; it can be positive, or it can be negative, BASED ON CHOICES THE USER MAKES.

The reason that was in bold, even though that makes it seem like I'm yelling, is the need to make this very, very important point:

What we now know is that the social media platforms use algorithms that push upon young users content which is harmful. Meaning, what the teen is exposed to goes beyond what they are choosing to view. An algorithm is deciding what they should see, and the suggestions that are presented have the potential to be very damaging.

But, what does that mean? Truly the best example is the stories coming from various congressional members. They are going in and creating fake profiles of 13 year old girls, and then watching what happens on that profile. I believe the first to do it was Senator Richard Blumenthal, and now Utahan Mike Lee is reporting having done the same thing. 

And what are they finding? See this quote from yesterday's KSL article: "Why did following Instagram's top recommended account for a 13-year-old girl cause our Explore page to go from showing relatively innocuous things like hairstyling videos to content promoting body dysmorphia, the sexualization of women and content otherwise unsuitable for a 13 year old girl?" Lee asked Mosseri. "What happened?" https://www.ksl.com/article/50308196/sen-mike-lee-to-instagram-youre-the-new-tobacco-whether-you-like-it-or-not

But then you read KSL comments, and people get hung up on each government official's overall political leaning and the generic understanding of social media. This means people are missing the point!

And the longer parents go missing the point, the more kids might well be exposed to the content that is pushed upon their children by an artificial intelligence algorithm. 

Now, anyone can go to my Facebook page and see that I "got off" (as defined by having I believe 9 FB friends) Facebook (the only social media I have ever had) weeks ago, after months, likely years, of knowing it was toxic to me. I have no problem with others knowing I have social anxiety. And, for me, social media worsened social anxiety. Did it also provide a form of communication/connection? Sure. But more so it worsened my social anxiety, and let's be honest, social anxiety is not that much fun. So, I finally...finally...decided to stop my exposure to it; not an easy task in our society. I now really only see what horse-related companies are having sales, and for me, that is the perfect use. ;)

Is social media all bad? Absolutely not. But do we all need to better understand how it works and how it might impact us? I would argue the answer to that is a resounding yes! I fear all the news coming out is simply not sinking in, and for social media to eventually improve, it needs to sink in. 

Pardon me while I leap off my soapbox. 

More on Social Media

Given the last post, the next logical question is "What can I do, as a parent?"

This is, of course, a very tricky question, as we knowing parenting teenagers is tricky in general. But, I have found that teenagers do best when things are simply explained to them in straightforward terms. Especially once a teenager has developed an eating disorder, it is common to walk on eggshells around them, never knowing when the next explosion might occur...whether that is an explosion of anger, or tears. 

But, as a professional, I never tiptoe. I just don't. And I have found that all clients, teens included, appreciate this the vast majority of the time. Teens are looking for direction. Sure, they want to believe they know all the things, but in the end, they also seek guidance from trusted adults. So, my suggestion is this:

First, explain what you have learned about social media and what they might have been exposed to. The response to this will vary, I'm sure, based on the stage of recovery from the eating disorder. Those later in recovery might easily volunteer what they have been exposed to, while those more protective of the eating disorder might deny. They might want the continued exposure, so they can learn ways to improve their eating disorder behaviors. 

I'm guessing I don't need to say a lot about what to do if your teen is open about what they have experienced. Listen to what they have to say, and then ask them how they want to respond, rather than telling them what they should do. We all know that works better with teenagers, and humans in general.

If they are resistant, that probably is answer in and of itself; it likely means they are guarding the information on their social media. At that point, you have a couple options: 1) keep trying to talk to them, or 2) notify their treatment team. Reality is, sometimes teenagers are more willing to talk calmly to their treatment team than their parents, unfortunately.

As I stated previously, right now, we don't know well enough what teens have been exposed to via social media, but it is likely that more and more of that information will become clear over the coming months. Remember, the majority of clinicians are not aware of this new information about social media exposure. Your child's providers will be better able to help as they are made aware of your child's specific exposures. 

 

Parents: What You MUST Know About Social Media

As most of us know, a whistleblower, Frances Haugen, recently testified in front of Congress regarding her knowledge of some of the dangerous actions taken by Facebook, Instagram and WhatsApp. Whereas her testimony covered a number of topics, most relevant to my work is the fact that it appears these companies use artificial intelligence (AI) to push diet and eating disorder content to young girls and young women. The extent of this is likely to continue to unfold over the coming months, but for now, what we know is that, in spite of this testimony and news coverage, it continues to happen.

For years, eating disorder providers have known that social media is risky for those with eating disorders. Studies have repeatedly shown that involvement with social media correlates to worsened body image, which is a precipitating factor for the development of eating disorders. As a result, providers have worked with adolescents and young adult to try to alter their usage patterns. We have recommended parents monitor for concerning content, and we have worked directly with patients to choose to change the accounts they follow, with an emphasis on following more positive messaging.

But, what we have not known is that, regardless of how we encourage our patients to use a different approach in their intentional use of social media, the AI algorithms have forced upon these same individuals content that is not within their control. THIS is what is so important for parents, and providers, to understand at this time. In short, simply being a certain age and gender is the trigger for being bombarded with pro-diet and pro-ED content, and there is nothing the user can do to change this.

Since this news came out, I have spoken to a few providers, including some at the top of the field, regarding their understanding of social media and its impact on those with EDs. And what surprised me was that NONE of them knew about this new finding, the impact of this algorithm. And we all agreed, this changes things in a massive way. No longer can we focus solely on encouraging patients to change their choices online, as simply doing that will not stop the barrage of eating disorder and diet content. So, what do we do now? There's not an answer to that question, but I pose some ideas below.

I have dug into the research on social media and eating disorders, knowing none of it has yet to address this new information. But here are some key takeaways:

1. In 2021, the overall social media (SM) usage rate in the US was 74%. In the EU, 88% aged 16-24 use SM. Globally, the SM platforms with the highest number of user are Facebook (2.449m), WhatsApp (2B), Instagram (1B) and TikTok 800M (Statista, 2020)
2. From 2014-2017, Facebook usage in adolescents 12-18 increased from 47% to 75.1% of users. A 2018 study showed highest use for adolescents was Instagram. (Clinical experience says that use of TikTok is also very high.)
3. In one study, 61.3% of females sought body image related products on SM. Engagement with health, beauty and physical health accounts have been shown to correlate with an increased drive for thinness.  Finally, increased time on SM was associated with lower self-esteem about appearance, which was related to increase dietary restriction. 
4. SM usage was positively correlated with body image dissatisfaction, and also with restricting, bingeing, purging, laxative and diuretic use, and drive for muscularity. 
5. Social media use increased pathology in those with lower self-esteem and higher social comparisons. Passive FB use, defined as viewing others' content, without posting one's own, and intensity of use, were linked to social comparison and poor self-esteem. Both of these were then linked to depressive and anxiety symptoms, which often underlie eating disorder behaviors. 
6. Longitudinal research has shown: Greater social media usage predicted greater body dissatisfaction and increased appearance-related discussions with peers 18 most later. Body dissatisfaction did NOT predict SM usage, meaning that SM, instead, negatively impacts BI. 

An important detail in reviewing this research is the differentiation between correlation and causation. Many of the studies have shown correlation between SM usage and ED pathology. But, correlation is NOT causation. So, to clarify, the correlations above show that those who use social media more, also have higher levels of body image dissatisfaction and Ed pathology, but it cannot say that the SM uses CAUSES ED pathology. However, this is where we can bring in clinical experience, and clinical experience backs this research; many clients report that their social media use played a major role in their eating disorder development and maintenance. As a result, most, if not all, ED treatment centers terminate the usage of social media while in their treatment centers, and recommend limited to no use upon discharge. 

Fortunately, there is some data that is able to look at causative factors. The few experimental studies have shown that young adult men and women who were exposed to images of same-sex "attractive" strangers in mock SM profiles reported poorer body image than those exposed to "unattractive" strangers, and exposure to “fitspiration” images taken from IG led to a more negative mood and body dissatisfaction than did exposure to appearance neutral control images. These data reinforce the reality that exposure to problematic images on SM significantly contribute to ED pathology.

This is all research conducted at the time before we were truly aware of the impact of these AI algorithms. So, all of this data that has been based on the content that users voluntarily seek is only exacerbated by the new reality, which is that increasing amounts of this content is actively pushed upon teens and young adults, AND the SM companies know that and, to this day, have not changed it. 

Yes, to this day, users report that this content is still pushed upon this age group. 

This changes the landscape for parents and providers. No longer is it as simple as encouraging our children and patients to choose wisely what they follow on social media. No, now we have to explain the reality that, simply due to their demographics (age and gender) this content is forced upon them each time they use SM. 

Fortunately, as I have started to explain this to the girls and women I work with, the main response is anger. Nobody with an ED wishes it upon anyone else, so the women I work with are enraged about this reality. (I will add, some have indicated that TikTok is the worst offender, so I'd recommend to all of those with EDs...well, and probably everyone in general, but that's another post...to get off of TikTok.) And, I believe, that rage in the mind of the highly intelligent and powerful girls and women with eating disorders can then result in change. But we must get the word out. Talk to everyone you know about this situation...from parents, to teachers, to providers, to teens and young adults. Everyone needs to unite in the fight against this attack from SM companies; an attack based in increasing income to advertisers, seemingly without worry about the impact on these girls and women. Moving forward, providers will start to get a sense of how much this newly recognized exposure has impacted those with eating disorders, but for now, it is important that those working with individuals with eating disorders know that this is something to look at. 

And yes, men are exposed to it also, just not at the same rates, it seems.

For Parents: First Few Weeks

Recovery from an eating disorder is a confusing process. Some improvements happen quickly, and others take much longer. And unfortunately, while you are waiting for those improvements that take longer, conflict around food continues in your home. That conflict is hard for you and your child with an ED, and it is also hard for your other kids. One of the things I monitor as families provide treatment at home is when siblings are starting to be overly impacted by the conflict, or by the ED itself. It can feel like everything evolves around food and the ED, and there's some truth to that. The ED is so loud and overwhelming in your child's head that of course it kinda leaks out everywhere, over all of you. 

Let's start with the things that can improve quickly. Fortunately, many medical concerns can resolve quite quickly with improved intake of food and water. Orthostatic hypotension, blood pressure, heart rate, and lab values can all correct quickly, and most often do. (That is most true for patients who are not purging in any way. If intake improves, but purging continues, these values can remain unpredictable, and ongoing weekly monitoring is needed until purging ends. Fortunately, purging is not as common in teens as it is in adults.) For reference, teenagers that are hospitalized for issues related to vitals and labs often find all the issues corrected in just a few days; food and water is an amazing healer! Patient will also report improved thinking processes and energy with just a week of sufficient intake, and overall, they seem to be happier, though they tend to be very hesitant to admit any of these things. Medical risk decreases significantly, as long as ED behaviors do not continue. 

However, as all of this medical progress is being made, the anxiety around food increases. The best way to think of it is to look at fear in general. Imagine something you are afraid of, and how you respond to it. Most likely, you avoid it. However, avoiding it only serves to continue, and potentially increase, your fear of it. So, for your child, he/she is fearful of food, and has avoided it. Now we are shutting down that option, and as you can imagine, fear shoots up. Without fail, those with EDs become convinced they will rapidly gain weight as a result of what we have them eat. They won't, but we cannot easily convince them of that, so don't even try to do so very hard. We just have to wait. And, what I have noticed over all these years, is that it takes about two weeks, on average, for that fear to peak and decrease. In two weeks time, we are able to prove that they can eat way more than they thought and barely gain any weight. We were not able to talk them out of their fear, but their body proves the fear to be wrong. Now, if only EDs were so easily convinced, right?? Treatment could then just be done. But, nope; they are very annoying disorders and they hang on as long as they can. The EDs "job" is to convince its host that we are all lying, and only it is telling the truth; it's truth is that food is bad and your child will gain lots of weight, among other things. And the only thing that can disprove that....is time. 

So, your job is to outlast that obnoxious ED. While your child is screaming at you about what you are serving for dinner, you want to try to remember it is the ED screaming, not your child. And so you do your best to get mad at the ED for them, because they are not ready to be mad at it yet. You will want to closely watch your phrasing and express anger at the ED, not your child. Your child is frightened, though is not acting like the scared kid you might be used to. No, the fear is coming out as aggression and cruelty at times. But, it is not your child; it is the ED. And, of course, sometimes you just want to back down and serve something easier, or otherwise negotiate with the ED. But in those moments, if you have the resources within you (you won't always; we all have bad days), you want to stand up to that ED and make it clear it will not get to win, in that moment, or in the future. 

But what do you do if the disorder has become too aggressive for you to stand, or is impacting siblings too much? First, you want to make sure the other kids are getting attention too. I know, I just told you you have to work EVEN HARDER. Believe me, I know this is not fair. At all. But your best protection against your other kids potentially learning that the way to get more attention is to be sick, is to make sure they get attention for being well. This makes your job even harder as I know you are tired. So, it doesn't have to be big stuff. Just little moments to show that you have not forgotten about them in the mess of the ED. And, if this level of ED chaos continues, we then start to look at whether a higher level of care is necessary. And that's not because you or your child failed; we just know there are some EDs that are really nasty, or maybe you are a single parent, and the expectation of managing the ED at home becomes too much. For many teens, once they realize their parents actually will send them to treatment, they are able to rein in some of the ED acting out a bit more, and it becomes more manageable at home. But for others, there are excellent treatment centers that can step in and help out until the brain is more healed. 

I know this might sound more pessimistic, but I want to make sure you realize you are not alone in this battle and in how difficult it is. It is very difficult. But stay the course. Follow what the treatment team recommends, and recognize that it is unfortunately a bit of a waiting game. But recognizing that it just takes time can also be empowering. I know it's a cliche, but you do have to look at recovery as a marathon, not a sprint. There's a sprint off the starting line, just to get all the medical stuff managed, and the treatment team put together, but from there, it's about persistence...just putting one foot in front of the other until you reach the end. And the end does exist. I promise. Otherwise, I could never do this job. 

For Parents: The Initial Session

 So, you are about to do the first session with your son or daughter, and you don't know what to expect; or, you just finished it, and have no idea what just happened! ;) I thought my best approach would be to kind of walk through what is typically addressed Day 1.

My first job, even though I'm a psychologist, is to assess your child's physical state. I might do weird things like take his/her pulse, and I will annoyingly grill you on your child's most recent vitals, labs, etc. As I have explained before, I have a bit of an odd job, given my training. I'm trained in talk therapy, right? But, in eating disorder treatment, what comes first is physiology. So whereas you come in potentially expecting me to to dig into your child's thoughts and emotions, this is not going to be the priority at this stage, and hopefully this post will help explain why.

Eating disorders, especially those that have resulted in weight loss, are brain AND body disorders. Weight loss and/or starvation (you can have either or both), impact their brain heavily. It changes the way your child thinks, and the way he/she behaves. You have likely noticed they have become more anxious, more depressed, more obsessed (particularly on food and weight, of course), and they explode in anger like they never have before. There's a good reason for this. In short, the part of the brain that is impacted is the frontal lobe; that is the part of the brain that is responsible for rational thinking, impulse control and decision-making. I think it always helps a bit when I say it's the part of the brain impacted by substance use also. We expect somewhat chaotic, irrational behavior from those using drugs, but we don't expect it from the overly compliant kids/teens that end up with EDs. So, it is helpful to realize that that part of the brain is "hijacked." And therefore, our primary job is to repair that part of the brain.

In addition, what we know about kids and teens is that they tend to get sick very quickly, and they tend to recover very quickly. In all my years of doing this, I have rarely had to refer an adult for admission for medical monitoring. In kids and teens, this is more common. One of the tricks with kids and teens is that we have to look not only at the amount of weight lost, but also the amount of weight they should have gained during the time of their ED, but didn't. I realize that didn't make complete sense. Basically, kids and younger teens are supposed to be gaining weight all the time. So, when they lose weight, say 10 pounds, they not only "lost weight" but also "failed to gain." So, let's say they lost weight on the scale in six months; but, during that six months, they were also supposed to gain 5# naturally. So, at the time of the assessment, they have actually "lost" 15 pounds. Adults only have to look at weight loss, as they don't have the "failure to gain" variable. 

In either case, the weight loss impacts the frontal lobe, and so we sees the symptoms I listed above. And, those exact symptoms, and the brain impairment, make it so insight-oriented therapy is not really possible at this stage. Emotions other than anger and fear are often shut down. The primary answer you hear to most questions is "I don't know." And often they don't know; their brains need healing. 

And that means weight gain. Many therapists want to avoid talking about weight gain, because it upsets the client. And it does, very much. But, I approach working with teens by respecting their intelligence and their ability to understand science. I separate them from their eating disorder, and what i have found over the years is that, yes, the eating disorder has a meltdown about hearing about weight gain, but your smart child can understand why the brain needs to be repaired. Admittedly, they would prefer their brain could repair without weight gain, but sadly, I'm a therapist, not a magician. ;) So, we are left with weight gain as the cure.

So, initially, you will find this talk therapist mostly asking about medical indicators, and also asking the same questions the dietitian asks; what does food intake look like, what does energy expenditure look like, etc. And then I'll start to explain what I explain here in this post, and more. The goal is for both patient and parents to understand where we start, what the focus must be, and it gives me a sense of how willing the kid/teen is to consider engaging in treatment at home. I will often explain that there are two paths to treatment: one is treatment at home, with parents providing the structure, and the other is treatment in a treatment center, with the treatment providing structure. Kids/teens (and adults with EDs) like to make up path #3, which is something, "I'm fine, I"ll do what I want." Um, no. That's a mythical path; one of the two actual paths must be chosen. 

The main task for parents and teens leaving that first session is this: 1) contact providers you have been referred to to create a full treatment team, getting in as soon as possible, 2) follow dietary recommendations, starting immediately (willingness to do so helps determine which of the two paths we will end up on), 3) separate the patient from the ED (asking parents and teen both to get mad at the ED while making it clear there is no anger toward the patient him/herself), and 4) for parents, begin to learn about Family Based Treatment, from the resources provided in my previous post. 

That's kinda it. That's really all we can do in that first hour, unless there's a need for a medical intervention immediately. I know it's hard to walk out not having all the answers from any of us on the treatment team, but trust that those answers will come and you will make your way through this, one day at a time.