From the mouths of interns....

It has been a long time since the last post, and I apologize for that. Things have been very busy, with Utah Center for Eating Disorders formally opening, and the hiring of Nicole Holt, RD. It has been exciting and good change, but comes with growing pains, of course. I have thought often of writing blog posts, but have not made the time. This week, however, I was so overwhelmed by the words of this past year's interns, that I decided trying to summarize their statements was the needed motivation to write again.

One of my passions is doing training and supervision. There is little training in grad school for therapists, dietitians or physicians with regards to ED treatment. I was trained in ED treatment many years ago by a man who was once the top of the field, and then fell, and have always felt that training graduate students or post-docs is my way to give back. I learned many things from this man, and have always referred to him as a brilliant mind who struggled deeply with ethics. Although I cannot say I do much like him, I can say he taught me the concept on which I have built my career and treatment of eating disorders. It was from him that I learned about the physiology underlying eating disorders, and this is what I have strived to teach therapists who want to treat eating disorders. I have been thrilled to have two psychology graduate students "interning" (for those in psychology PhD land, yes, this is the wrong term, but I find it more respectful than "practicum student.") at Utah Center for Eating Disorders.

This week, they passed on their wisdom to this next year's interns. And as I listened to them talk, I realized how many things about ED treatment that slide right past me after years of doing it day in and day out. I will not pretend to quote them, but instead summarize parts of what I heard them say.

They spoke of the awareness of the gravity of the work they were doing. They stated it was some of the most frightening and intimidating work they have done, largely because they learned the physiological impact of the disorders, and accepted the reality that these are the most lethal psychiatric disorders. They spoke of awareness that something could go wrong physically when neither they nor the patient expected it. They spoke of the impact of truly seeing the physical impact, and experiencing deep emotional reactions of sadness and fear as they worked to help those with EDs. I had said to them a couple of times that their reactions really impacted me; through them, I realized "my eyes don't work anymore." I don't see body size as much anymore and react less, simply due to desensitization. It was eye-opening to see EDs again from the perspective of someone who has not been doing the work for so long.

They spoke of the difficulty of taking on more directiveness in patients' lives. After all, in therapy, we are to "accept the client where he/she is at." Well, we cannot do that. We cannot accept an eating disorder, or at least that is my approach. So, we do become more involved, provide more direction, and set some hard lines. It was rewarding to me when they were able to see that this can work, that their patients did not run off and get upset with them for being firm, but instead respected their willingness to jump in and fight against the disorder.

They said many more things, but this cannot be eternal, so I will leave it at that. The bottom line is that working with them and seeing their success in helping patients overcome their disorders was very powerful and rewarding. I learned they were often intimidated by the gravity of the work they were doing; I also learned they were REALLY good at hiding that most of the time!

This is intimidating work, but also incredibly powerful and rewarding. One of the things that irritates me the most is when therapists or other professionals label eating disorders as untreatable. This is far from the truth. And what these two showed was that with a little training, supervision and support, they were able to help their patients change dramatically. And I continue to believe that a major part of that was truly understanding the physiology underlying the disorder. So, if you are a therapist that wants to treat eating disorders, my advice is to prioritize learning the physiology. It goes outside the bounds of typical therapy, but is invaluable. And, as I had to remind them a couple times, past the physiology everything else is "just therapy," and I didn't need to teach them about how to do therapy.

Congratulations Angie and Julia on your internship placements. You will be greatly missed. And welcome on board Kendrick and Larissa! It should be a fun ride!

Announcing: Utah Center for Eating Disorders

I suppose it has been woefully obvious that I have not been posting for a few months. Many things are going on, the largest of which is this announcement! My private practice has now expanded, and will now be known as:

I truly do plan to return to blogging once the dust has settled. Thanks for your patience and support!

Eating Disorder Awareness Week 2013

Please join us for the following events:

February 26, 6-7:15pm
Sick of Dieting? A Different Approach to Eating and Weight: Health at Every Size and Intuitive Eating.  
 Elena Yorgason, RD and Julia Mackaronis, MS

February 27, 6-7pm
You Mean Everyone with and Eating Disorder Isn't Tiny?: Hidden Eating Disorders
  Addressing Binge Eating Disorder, Exercise Addiction, Orthorexia
Angela Hicks, PhD

February 28, 6-7:30pm
What can Family and Friends Do? Recovery Panel Discussion
Wendy Hoyt, PhD and Recovery Panel

All presentations will be held at Westminster College, 1840 S. 1300 E, SLC 84105
Health and Wellness Center Special Events Room

We really hope to see everyone there! Please share this information!

Thanksgiving ideas

Of course, Thanksgiving is a holiday dreaded by those with eating disorders. They are scared of the amount of food, what might happen with food, what family members will say to them about their eating. So, here's a few ideas for making Thanksgiving more enjoyable. (Please keep in mind, though, that if you are a patient in treatment, none of what I say should override any plans you have made with your treatment team.)

1. Yes, our society has made Thanksgiving about food. But, you can choose to make it about family, or time off work, or whatever you want to make it about. The food is just food.

2. Our society advocates for starving all day and then overeating the Thanksgiving meal. What I recommend to all my patients is that they treat Thanksgiving as just any other day and any other meal. So, eat meals and snacks throughout the day, and then view the Thanksgiving meal as just a normal meal.

3. That said, it is okay to overeat Thanksgiving some. What you want to protect yourself from is either restricting or bingeing. But, at the Thanksgiving meal, a lot of good foods you maybe don't normally have are available, so it's okay to eat more than usual. Nothing terrible will happen to your body, and in fact, your metabolism will just speed up in response.

4. Use family to support you when you are struggling. Before even getting to the Thanksgiving festivities, identify who is going to be your support person and let them know you have chosen them. When you are having a hard time, pull them off to the side and talk to them and let them help in whatever way.
     a. If you are the family member who has been identified to help, remember this key phrase: "What
        can I do to help?" This saves you from feeling like you need to fix everything, which would likely
        frustrate your loved one with an eating disorder.

5. If it helps, plan out what you are going to eat before the meal itself so you are less likely to panic in the moment.

6. If you are doing Intuitive Eating, remember all foods are good foods, no foods are bad foods! You are "allowed" to eat anything no matter who or what has said something about that food. Eat when you are hungry, stop when you are full, and remember you can always have leftovers later.

7. If you are concerned about bingeing, and have the "last supper" mentality, wherein you feel pressured to eat more because you are afraid there you must eat it all while it is available, consider going ahead and making yourself a plate of leftovers before you eat your meal so you can be confident you can have later the foods you really enjoy. Yes, this will be unusual, but your family should be able to support you in taking this step as managing your eating disorder well.

But, most important, remember Thanksgiving is not truly about the food. You are there to spend time with family and/or friends and enjoy the day, or the day off, or whatever is enjoyable! Happy Thanksgiving!

News coverage, part II

The aforementioned news outlet has again contacted me to come on air, this time to address EDs in men. I spoke with the reporter at length, expressing my concerns about the previous story, and was told this reporter would not do the same thing. So, I agreed.

But, I just read the story in GQ that this reporter is basing her story on, and it is yet another ED story that talks about behaviors and weight, etc. (Why is it so rare that a news outlet can manage to pull off a story that does not glorify EDs??) And, as much as this reporter might agree to not do the same story, reality is I don't have any ability to reject participation once the interview is done.

So, the question is this: Does the benefit of talking about EDs in men outweigh the risks of the impact of another potentially glorifying story?

Please, thoughts?

The person is not his/her disorder

Some of you may have seen the local news story about anorexia the other day. Of course, I support anyone with an eating disorder getting the support they need, but I found the news story to be so inappropriate in so many ways, a few of which I will detail here.

As my patients know, one of my huge pet peeves is the use of the words "anorexic" and "bulimic." When I wrote my dissertation, which was largely on cutting, I drove my advisor nuts because I refused to write the word, "cutter," and instead made my dissertation significantly longer, I am sure, by writing "individuals who engage in self-harm" and similar phrases. So, here's the point: Do you call someone who has cancer, cancer-ic? No, you don't. So, why would someone with anorexia be "an anorexic." The person is not his or her disorder, and in fact, identifying with the disorder is one of the major hurdles to overcome in treatment. So, hearing "anorexic" over and over was very upsetting. This patient did not need to identified as her disorder. She is a person, with a disorder; she is not actually a disorder.

News stories seem to feel such pull to glamorize eating disorders also. Maybe glamorize is not quite the right word. But, they feel the need to show exactly what symptoms the person engages in, his/her weight, etc. All the things that those with eating disorders compete over. So, maybe the news story helped those who know absolutely nothing about EDs understand what behaviors make up an ED, but I was frustrated because I knew those with EDs who were watching the story were being triggered right and left. Some simple research on the part of the reporters would have helped them understand the disorder better, and know what they decided to focus on not only is not unique, but likely triggering to others with the disorder about which they were trying to educate.

So, what could the story have been about instead? How about using this woman's story, without all the details, to present the message that there needs to be greater insurance coverage for treatment? There would have been a lot of benefit to trying to engage people in the fight against insurance companies, or to strengthen laws regarding mental healthy parity. People left that news story knowing what symptoms make up anorexia, and one individual that has the disorder. So much more good could have been done by focusing less on the details, and more on what needs to change within our healthcare system when it comes to eating disorder treatment and coverage.

I want to make it clear I am not criticizing the woman in the piece. She has an eating disorder and deserves access to treatment and, I'm assuming, took the steps she thought could help her get help. I'm criticizing those who were more in the position to treat this story differently, and create greater benefit.

Update: I was just called by the new outlet to come on air live for their follow up story. I refused on principle, and let them know my concerns with their approach to this story. So, hopefully the information I gave them will help change their approach in follow up.

Opinions on weighing

A recent discussion on a professional listserv was regarding whether or not providers weigh patients and communicate their weight to them. At about the same time, a normal weight patient in the process of learning Intuitive Eating commented to me that she felt that being weighed by her dietitian went counter to learning IE, which I thought was an interesting point, so I brought this question to the listserv.

Everywhere I have ever worked has not shown the weights to patients, instead making the treatment team responsible for weights and encouraging patients to not focus on weight, but to instead focus on becoming healthy. Which is what still makes the most sense to me. Weight has recently been such a topic of debate within the field, with of course the "old school way" being to focus likely too much on weight, which has resulted in many problems getting appropriate insurance coverage for EDs. The insurance industry took the height/weight numbers identified in the DSM, and used these to justify terminating treatment ridiculously early. As a result, I believe the weight criteria will be removed for the DSM-V, but don't quote me on that. But then the "new school" seems to, in my opinion, go a little overboard in saying we shouldn't care about patient weights at all, and instead focus solely on physical signs of starvation.

Personally, I think it is more realistic to be in the middle ground. Reality is that weight is one of the more concrete indicators we have to work with in treating eating disorders. But, it certainly is not the be all and end all, since reality is nobody can ever know what is the "right" weight for someone. So, I both track patient weights, through a dietitian or physician, but also ask patients questions that assess for cognitive and physical effects of starvation. I don't think you can do just one or the other because, in my experience, sometimes the cognitive effects don't necessarily change immediately upon the patient seeming to get to a healthy weight, but instead develop over the next little while, while they maintain that healthy weight.

I think most everyone agrees we need to weigh patients who need to gain weight; I saw no debate of that point. But then there's the debate of whether the weight should be shown to the patient. I can see benefits to showing the weight, especially for patients who dramatically overestimate what they weigh or how quickly they are gaining. But I guess I'm not sure why we would show weights for any other reason. To show weights seems, to me, like it perhaps reinforces the message that the weight is important. Though, again, I'm sure there's a middle ground wherein the weight is shown, but also discussed as being not nearly as important as physical and emotional health. I guess I'm just concerned that showing weights could end up taking up more therapeutic time than if the individual just learns to not focus on weight without seeing and reacting to it.

To address my question of weighing in those of normal weight and learning Intuitive Eating, Elyse Resch, one of the authors of Intuitive Eating, did confirm what my patient  had said, and argued that patients who are learning IE, should not ever be weighed, as this does propagate the focus on weight and number. But then, we have had patients who want to turn over weighing to us for fear that if their weight is not tracked, they will gain weight and nobody will know. But then others feel shame and guilt even stepping on the scale, perhaps due to things like weigh-ins at Weight Watchers.

So, as you can see, this is proving to be a bit of a confusing topic! As far as I heard on the listserv, nobody has ever actually researched the effect of doing blind vs non-blind weights. So, I thought we should do our own, terribly informal, qualitative research here, and ask for your thoughts on blind vs non-blind weights. Please, comment away!!