5 Answers to Common Questions From Those Struggling with Anorexia

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By: Melissa Gerson, LCSW

Although every client is different, here are the five most frequent things we hear from anorexia patients at Columbus Park, together with our response:

1. “Why can’t I stop thinking about food?”

That’s what happens when your body is starving.

Chronic food deprivation and loss of body weight results in heightened interest in food.   When your body weight drops below a comfortable set point range, the brain switches into starvation mode—metabolism slows and hunger signals pick up.  This focus of the starved mind on food may lead to increased interest in food preparation (often for others, not oneself), obsessive planning of meals, extending eating experiences for long periods, reading about recipes, and/or looking at photos of food.  Many describe this fixation on food as persistent and profoundly distressing.  Weight restoration helps reverse these effects.

2. “My weight isn’t low enough; how can I be starving?”

Your body feels starved long before you look emaciated.

The popular image of anorexia and under-eating is that of someone emaciated. While some people do get to this point, most enter starvation mode at higher weights.  Each of our bodies has a set point range (usually about a 5-7 pound range) it works to maintain.  Set points vary by individual—based on genetics, lifestyle, height and weight as a child, and where the body was prior to the start of the eating disorder.  Once weight falls below your set point, your body enters starvation mode.

3.  “Why can’t I keep exercising a lot? It makes me feel calmer.”

Yes, exercise can be relaxing, but too much can impede your recovery.

Mammals who are in areas of famine show remarkable strength and single-minded focus to migrate to areas where food is more plentiful.  There is some evidence to suggest a similar effect in those with anorexia; a kind of hyper energy even in the absence of adequate food.   Exercise also stimulates the production of neurochemicals which serve as natural soothers.

4.  “Why can’t I limit my diet to just healthy, clean foods?”

Is it really about health?

I’m all for healthy eating – but “healthy and clean” eating often gets taken to unhealthy extremes.  When clients with anorexia frame healthy, clean eating as in the service of health, I remind them that this extreme restriction and rigidity has actually had the opposite impact; it has taken them to a dangerously unhealthy place (hair loss, poor circulation in extremities, slowed heart rate, loss of periods in women, and more).   These clients typically require intensive medical oversight due to their compromised health – hardly a “healthy” place.  It’s not really about a pursuit of health; it’s about taking eating habits that might be considered ideal or even virtuous to an extreme.

5.  “Why can’t I get better without gaining weight?”

It’s not possible.  Your body and mind simply cannot recover if you remain underweight and malnourished.

The consequences of maintaining a low weight include constant thoughts about food, low energy, avoidance of social situations, isolation, poor sleep, inability to focus, and obsessing about the number on the scale. Clients sometimes want to shed those un-pleasantries without actually gaining weight.  It can’t be done; they are inseparable.  Achieving a full and balanced life means restoring health and balance to your body.  Most of our clients with anorexia notice that as they restore weight they feel better, not worse.  Depression and anxiety symptoms remit along with obsessive food and body thoughts.  They develop the kind of flexibility required to re-engage socially.  Physically, they feel stronger, more energetic, and better able to concentrate.

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Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

To learn more about treatments offered at Columbus Park head to www.ColumbusPark.com

A Thank You Letter to My Therapist

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By: Ericka Christina

To my therapist,

After almost eight years of working with you, I can say we have established a pretty solid relationship. We’ve worked through so much more than just my eating disorder symptoms, and we have uncovered layers of trauma to reveal a strength I never imagined I could possess. There have been highs and lows, and I’ve lost count of how many times I think you have saved my life.

Today, during my session, we talked about my progress, and the option of coming to therapy less frequently or even stopping all together. While I consider myself stable right now, stopping is not an option. I value the time I have with you, and it is the highest form of self-care for me. As I reflect on the years of work we have done together, I am in awe of the progress and changes in myself. Last year, I didn’t have to schedule an emergency session to figure out how I would cope with a Thanksgiving meal, and I didn’t need to have my phone with me at the dinner table in case I needed to send an SOS text. For this, and so much more, I’d like to say thank you.

Thank you for all of the hard work and dedication you have shown me through the years. There are countless examples that come to mind, but some stick out more. You listened with support when I blamed you for taking away the thing that meant the most to me, and then, you let me grieve that loss (over and over again) before helping me to see that I no longer had a need for the eating disorder. Thank you for having me set a phone alarm to text you daily when I needed encouragement to complete meals. I labeled the alarm as a “reminder that someone cares,” and though it is no longer an active alarm, I’ve kept it on my phone.

Thank you for signing into Recovery Record, reading my food logs and leaving feedback. It made me try harder to “do the next right thing” because I knew there was accountability. Thank you for collecting my scales (yes, plural!), storing them safely away from me and for showing a genuine happiness whenever I had meal victories. For what may seem like little things (but to me, made a world of difference), thank you.

From writing encouraging letters for me to save to read when I needed a boost to preemptively supporting me during holidays and transitional periods by sending a quick text, I appreciate every bit of it. You were never afraid to promise me that I would be OK and because I trusted you more than I trusted myself, I chose to believe that. It became a reality. You relentlessly worked to help me discover my self-worth and reminded me of reasons to recover. Most of all, thank you for giving me the constant reassurance that no matter what, at the end of the day, I have a person in my corner and I’m never alone in this recovery journey. Even though I don’t see you as often right now, you will continue to be the voice in my head that helps me to choose recovery every day. For this, I am forever grateful.

About the Author: Yogini. Social Worker. Avid napper. Recovery Warrior.

I Didn’t Think Recovery Was For Me

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By: Anonymous

I never thought I would recover. I wasn’t sure if recovery from an eating disorder was even a real thing. Let alone possible for me. I never thought I would want to recover even if it were a possibility. I remember leaving a clinic that I didn’t want to go to in the first place; I was supposed to go get my things and come back in the morning to start inpatient therapy. I wasn’t ready. Are we ever really ready? I guess that the answer must be yes, or at least that we must kind of want to try, anyway. But not yet. I had to get worse before I got “ready.” Because eventually, I had to decide — did I want to die or not? I wasn’t really sure if I cared anymore. That’s the decision that it ultimately comes down to if you let it. Or it did in my case anyway. I’ve never felt more alone or more ashamed. And I’ve never liked myself less. And my family was worried about me, and I hated myself for making them worry.

Eventually, I started to worry about me too. “Do I have electrolyte imbalance(s)? Am I going to lose consciousness and wake up in a hospital? Do I have osteoporosis? Am I infertile? Does it even matter? I can’t even take care of myself; how could I ever even think about taking care of a child?” I didn’t know what to do. But it seemed I had learned exactly what not to do. For a while, I actually I thought I was in control. I thought had such great willpower. And I guess it did start out that way. If you can deny yourself a basic human need, what can you not do?

But somewhere along the way, I lost that control. I remember seeing a photo of a note on the inside of a toilet lid that said “who’s in control now?” It really stuck with me. Looking back now, I feel confident I will never go back because I see now that there is no winning. No end goal. No staying in control. No being perfect. I would never be “good enough.” I remember setting and reaching weight goals, and I never felt even a little better. Not once.

I never thought I’d be here today. Here, drinking coffee that’s not black, studying so that I can try to figure out how to help others like me (or unlike me). I never would have considered that my thoughts or my story may be worth sharing. I never thought I’d talk or write about this. But what have I got to lose? If it helps anyone, it was worth it. And I like to think it couldn’t have all been just for me. Now I even have a recovery tattoo, for myself, and for anyone else who may need it. To remind myself how far I’ve come. And that there is hope. And to know that I am not alone. None of us are alone. Asking for help is not a sign of weakness; it is a sign of strength. Recovery is possible. You are more than enough.

Specialist Supportive Clinical Management Treatment

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By: Melissa Gerson, LCSW

In my work as the Clinical Director of a specialized eating disorder treatment center, on occasion I will meet individuals who continue to struggle with severe anorexia after having received multiple treatments over the span of years. Severe and enduring anorexia, also known as Longstanding Anorexia Nervosa (L-AN), is often associated with poor quality of life, resistance to treatment and treatment failures. Often, individuals suffering from L-AN will report that they feel disheartened by their failed treatment attempts, report negative treatment experiences and a sense of skepticism about services and recovery, altogether. Specialist Supportive Clinical Management (SSCM) is a novel treatment approach that has been gaining ground within the field. It has now been reviewed by professionals and compared to alternative interventions such as CBT. Specialist Supportive Clinical Management is well-suited to clients with L-AN as it is developed around a central principle of aligning with a client’s goals and supporting them as willingness and resistance ebbs and flows. As defined in an article published to International Journal of Eating Disorders, SSCM “is an outpatient treatment that could be offered to individuals with anorexia nervosa in usual clinical practice by a provider trained in the treatment of eating disorders. It combines features of clinical management and supportive psychotherapy.”

Researchers of SSCM found it limiting that in most studies, traditional interventions such as CBT, group therapies, nutritional treatments (e.g. dietary counseling, nutritional advice) and family therapy are evaluated. Beyond these studies, little is known about the effectiveness of psychotherapy treatment for L-AN and there have been few attempts to identify or develop novel treatment methods. It was here in this small space that a manual for SSCM was developed. SSCM is composed of two major components; Clinical Management and Supportive Psychotherapy.

Clinical Management

This term has been conceptualized by researchers as “good-quality care, delivered by a competent clinician with our without the addition of any specific treatment regimen.” The lack of specific treatment regimen is supported as the article claims “There is mixed evidence about whether more specialized psychotherapies or treatments confer added benefit to good clinical management. Differences in outcome between known effective treatments and good clinical management may be small or negligible.” Clinical management includes education (symptoms and diagnosis, etiology, warning signs of illness recurrence, prevention strategies and what will happen if it is left untreated), care, and support, and fosters a therapeutic relationship that promotes adherence to treatment. For individuals with anorexia nervosa, treatment emphasizes the resumption of normal eating and the restoration of weight. A main goal of the clinical management component is to establish a stable rapport and therapeutic relationship with a client as that relationship promotes adherence to the treatment regimen and compliance in taking medications. An important factor that will enhance the effectiveness of clinical management is an open discussion about fears or prejudices on the part of the client as they relate to mental health care. It will also be important for the client to present their ideas as they differ from those of the clinician. Sharing the diagnosis with the patient in this way enables the clinical to provide, and the patient to receive, ongoing care and treatment.

Supportive Psychotherapy

The delivery of information and psychotherapy within SSCM must be done in a supportive manner. Supportive Psychotherapy is best defined by L. Luborsky (1984) as “demonstration of support, acceptance, and affection toward the patient; emphasis on working together with the patient to achieve results; communication of a hopeful attitude that the goals will be achieved; respect of the patient’s defenses; and focus on the patient’s strengths and acknowledgment of the growing ability of the patient to accomplish results without the therapist’s help.” Supportive psychotherapy has a conversational style, using techniques such as active listening, verbal and nonverbal attending, open questioning, reflection, praise, reassurance, advice, and therapist self-disclosure.

Phases of Treatment:

SSCM is divided into three phases. Phase one includes a patient orientation to SSCM, identification of target symptoms and goals for weight gain and normal eating. The features are agreed upon by both parties. Middle phase includes the ongoing monitoring of target symptoms and support/encouragement. The final phase involves discussion of issues related to termination and planning for the future. In this particular clinical trial, sessions were scheduled 1x per week for 20 weeks. It is important to note that the time frame for SCM is flexible, and therapy contracts are re-negotiable.

Throughout the course of treatment the provider maintains that the client must stay medically stable throughout but otherwise, is largely responsive to the client. While a main focus of treatment is weight restoration, it is not the primary focus. Instead, the focus is on improving quality of life and in doing so, invariably eating, food and overall health are addressed in a way that may be experienced as far less threatening for the client. Physical status is evaluated throughout via weigh-in’s and blood test monitoring in addition to the delivery of nutritional education and advice.

How does this differ from other therapeutic interventions?

SSCM was specifically designed so as not to overlap with the key features of CBT or IPT. As practiced in this clinical trial, supportive therapy allows discussion of personal concerns and issues on a session by session basis and as identified by clients as opposed to challenging irrational beliefs (CBT) or focusing on interpersonal issues as facilitated by the therapist (IPT).

While further research of this promising therapy is warranted to evaluate the effectiveness of SSCM, it is an important tool for clinicians to evaluate as it may impact their clinical treatment of L-AN.

References:

McIntosh, V., Jordan, J., Carter, F., McKenzie, J., Bulick, C., Joyce, P., (2006) Specialist Supportive Clinical Management for Anorexia Nervosa. International Journal of Eating Disorders, 39:8 625–632.

Luborsky L. Principles of psychoanalytic psychotherapy. New York: Basic Books; 1984.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

Acceptance Commitment Therapy in Eating Disorders

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By: Melissa Gerson, LCSW

Imagine this: You walk into a social gathering to find yourself among a group of people you don’t know. Immediately thoughts begin flowing into your mind: “I don’t know anyone here!” “Who should I talk to?” “If I am standing here talking to nobody, people will think I am a loser” “What if I go up to someone and they don’t want to speak with me.” “I look so awkward right now” “This shouldn’t be so hard for me.” The next thing you experience is the your heart pounding so loud you are convinced others can hear it, beads of sweat dripping down your forehead and an extreme desire to flee the situation.

In this scenario, the attachment to these thoughts and worries led to an emotion we may know all too well: anxiety. In our work with eating disorders, we find that anxiety is often a trigger for destructive food behaviors: restriction, binging, purging or some combination.

From the perspective of ACT, also known as Acceptance and Commitment Therapy, the intensity of anxiety experienced in this aforementioned scenario arises from a process known as cognitive fusion.

Cognitive fusion is a central concept in ACT, which is an empirically based psychotherapy developed by Stephen C. Hayes . Cognitive fusion is a process, in which we are bound to and inseparable from our thoughts. You can say that we are welded or bonded to them so strongly that we begin to see them as more than just thoughts, and rather as absolute truths or facts.

Rather than noticing or observing, “I look so awkward right now” as a thought, in a state of fusion, we experience it as a fact about reality: “I look so awkward right now and therefore I am so awkward right now.” We become stuck to these thoughts, which fuels their power over our behavior. In other words, these thoughts may motivate us to avoid engagement in conversation with others, leave a social gathering or perhaps engage in maladaptive behaviors to reduce the unwanted negative emotion that ensues, all of which causes us to lose contact with reality and our experience with the present moment. Rather than creating contact with the world of direct experience, we become lost in the world of language.

So how can we recognize when we are in a state of fusion? According to ACT, we can watch out for fusion in 6 areas:

1. Rules

Are there any implicit rules that you find you hold for yourself about work, relationships or about life in general? Do you ever notice yourself saying words like should, can’t, must, have to, ought?

2. Reasons

Do you find yourself generating rationales about why change is unattainable for you specifically? Fusion to these thoughts can get in the way of creating movement necessary for recovery. It reduces self-efficacy and prevents us from making the change we are capable of making.

3. Judgments

Although judging in certain circumstances can be important and even useful, many judgments can be unhelpful and harmful. Fusion to judgments about ourselves and others including, “I am ugly” or “I am an addict” can be detrimental and preclude us from developing meaningful lives. These judgments of evaluation enhance our suffering by disconnecting us from facts about ourselves and the world around us.

4. Past

Although the past has already happened, you may find yourself stuck to certain moments in your past. Fusion to these thoughts detaches us from the present moment and the world of direct experience. We may lose touch with things right in front of our eyes that may bring us joy and pleasure.

5. Future

Although the future has not happened yet, do you find yourself worrying about things that might happen? Fusion to thoughts about the future pulls us away from being effective in the present moment and may exacerbate high levels of anxiety.

6. Self

Are you attaching to a certain description of yourself? These can include thoughts like “I am depressed” or “I am sick.” Sticking to these thoughts make them rigid and inflexible and therefore, can prevent us from becoming the people we want to be living the lives we want to live.

The good news is ACT has a solution. From the ACT perspective, the way to reduce psychological suffering is to change our relationship to distressing thoughts. This can be achieved through a process called Defusion. Through defusion, we learn to create distance between ourselves and our thoughts, which help us see them for what they are: words, images and pictures. This is not to say that these distressing thoughts will not enter our mind, rather defusion teaches us that when they do, they do not have to dictate our behavior. Through this separation, we can begin observing thoughts as statements that may or may not be true and that can enter as well as exit our minds.

Harris, R. (2009). ACT made simple. Oakland, CA: New Harbinger Publications, Inc.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

You Don’t REALLY Believe That?

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By: Erin Parks, PhD

Having appreciated the humor that comedians have poked at“awareness” campaigns, I wanted to be very intentional about what, exactly, I wanted to make people aware of during Eating Disorder Awareness Week (#EDAW). And then the answer hit me in the face.  I was interviewing a clinician—she was kind, funny, had an excellent resume—and I was telling her about the culture and theoretical orientation of our center.  I told her that our research uses neuroimaging and genetics to look at the neurobiological underpinnings of eating disorders and that our three clinics take an agnostic approach, consistent with Family Based/Maudsley therapy, in that we truly believe that parents do not cause eating disorders and they are not to be blamed.  The applicant smiled, met my gaze, raised her eyebrows, and leaned in as though we were about to share a secret…

“I understand why you tell the parents that, but surely you don’t really believe that.”

really do believe that parents do NOT cause eating disorders.  I share that belief with our directors, our researchers, our clinicians, our office managers, our dietitians, our cooks, and every last member of our staff.  We believe, that like cancer and epilepsy and schizophrenia and autism, there are neurobiological and genetic causes to eating disorders.  But it is easy for US to believe this—we spend our days working with wonderful parents. These parents remind us of ourselves; they’ve been trying their very best to raise happy and caring children. These parents are shocked that their child has become so ill, because similar to the interviewing clinician, they too had previously believed that poor parenting caused eating disorders.

I wish I could say that was the first time in an interview that someone had asked me if I secretly blamed the parents, but there are many intelligent and caring people—clinicians, teachers, neighbors, friends—who believe the common myth that parents cause eating disorders.  This myth of parental causation has existed for many illnesses and most mental health disorders: schizophrenia, ADHD, autism, depression.  But it feels particularly pervasive for eating disorders—why is that?

Eating disorders have the highest mortality of any mental illness—rates that many studies suggest may be comparable to common pediatric cancers.  And yet, when we hear of a child getting diagnosed with cancer, friends and neighbors spend very little time wondering what caused the cancer and instead energy is focused on treating the cancer and supporting the family. The same is not true when a child is diagnosed with an eating disorder. When I asked a group of caring, intelligent parents what thoughts came into their minds when hearing of a 13-year-old being hospitalized for an eating disorder, they confided that they wondered about the parents: did they diet in front of their children, did they pressure them to succeed, what messages did they give about body image? There is this cultural sense that there is a right way and a wrong way to raise a child, and doing it incorrectly can cause problems—including eating disorders.  So what is the right way?

There is a prolific stream of (conflicting) parenting articles offering the latest opinion/theory/research on how to approach feeding your family.

Don’t feed your kids sugar: they’ll become addicted.  Feed your kids sugar: depriving them will make them binge later.  Make your kids try new foods: if not, they’ll never develop a healthy pallet.  Don’t worry if your kids are picky eaters: they will have disordered eating if you make food a battle.  Don’t bribe your kids with food: food shouldn’t be a reward. You can bribe your kids with food if it helps them eat their vegetables.  Hide vegetables in your kids’ foods. Don’t lie to your kids about what’s in their food.  Let your kids eat as much or as little as they want: follow their lead so they become intuitive eaters.  Your kids should be on a schedule, including meals: structure is good for kids. Gluten is bad.  All food is good.  Kids have to eat meat.  No kids should eat meat.  Dieting is bad: teach kids to love their bodies at all shapes.  Model healthy eating: we have an obesity epidemic.  If you put your kid on a diet they will develop an eating disorder.  If you don’t put your kid on a diet they will become obese and get diabetes.  Confused yet?

The conflicting advice continues when the parenting articles discuss achievement.  Parents should teach their children art and music and sports and STEM skills and foreign languages.  Parents enroll their children in way too many activities.  Parents should let their children choose their activities. Tiger Moms vs Free Range Kids. Kumon vs Montesorri.  It’s your fault if your children get hurt—you should have been watching them.  Don’t be a helicopter parent and let your children play unsupervised.  Challenge your kids, they need frustration and failure—they need grit.  Don’t push your kids—they’ll develop eating disorders.

Parenting is an unyielding stream of decisions, creating infinite iterations of parenting.

Our clinic has worked with hundreds of families and while their home cultures slightly differ, most are just typical families, trying to find moderation amid the sea of conflicting internet advice when it comes to feeding and raising their kids.  No matter what food and parenting choices they made for their families, somewhere there is an expert saying that they made the wrong choice and that is why their child has disordered eating.

A confession: I have two toddlers and I consume the endless stream of conflicting parenting articles that fill my Facebook feed and the Huffington Post. Sometimes I WANT parents to be the cause of language delays and college dropouts and cancer and bullying and ADHD and eating disorders. Then I could just parent correctly and guarantee that nothing bad will ever happen to the two children I love most in this world.  But that is not our reality.  In reality there are pros and cons to all decisions and there are complex causes to complex issues.  The reality is that parents everywhere are trying their very best, doing a very good job, and are parenting in ways that may look very similar to how each of us parent—and their children are struggling with difficult and scary things—including eating disorders.

Many articles this week will talk about hypothesized causes of eating disorders—food culture, focus on achievement, the media—and while it can be important to think about the negative consequences of some aspects of our culture, this search for a singular cause can feed into the culture of blaming the parents.  The majority of parents will diet, the majority of women will feel bad about their bodies, the majority of teens will feel pressure to succeed, and the majority of images of women in the media will be distorted and unhealthy—and yet the majority of children will NOT get eating disorders.

I hope we can turn the conversation to the successful evidence-based treatments that now exist for eating disorders and how we can improve upon them so that they are effective, accessible, and affordable for everyone.  I hope we can discuss how parents know their children best and can be the most wonderful treatment allies in helping their children fully recover from an eating disorder.  I hope everyone can now believe that parents are truly, really, not to blame.

This post originally appeared on ucsdeatingdisorders.tumblr.com


About the Author: Dr. Erin Parks is a clinical psychologist and the Director of Outreach and Admissions for the UC San Diego Eating Disorders Center for Treatment & Research . She is passionate about educating clinicians, parents, and the community about the neurobiological basis of eating disorders and the evidence-based treatments that are now available. Dr. Parks wants to help society view mental illness as brain illness–narrowing the funding and resource gap between physical and mental disorders.

Crafting an Empowering Therapeutic Journey

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By: Dr. Whitney Robenolt

One of the hardest parts of beginning your treatment journey is seeking out therapeutic support. The therapeutic process is typically associated with a state of vulnerability that at times can promote apprehensive thoughts, especially for those seeking support for the first time.

As an outpatient psychotherapist I find it important to advocate for individual treatment, in order to promote the notion that you can be an active and empowering member of your therapeutic journey. Finding the right therapeutic match may not always occur the first time you step into a therapist’s office. However, it is important to be hopeful; you will find your right match! Conduct research. Search for specialized treatment providers in your area. Seek out support groups in your area, asking others their recommendations for powerful therapists. Contact local therapists of interest requesting a consultation to discuss the potential treatment process, including their knowledge of eating disorder etiology and treatment modalities.

Mental health symptomatology and presentation, especially within eating disorders, is not always black and white. Those who present with disordered eating patterns do not always fit into a specific mold. Eating disorders are not biased, and it is important that your future therapist will provide effective support and treatment for your individualized needs. Ask questions. Many of the individuals I see for psychotherapy are often hesitant to initially ask questions. I believe questions are an integral part of the therapeutic process. It allows you to become an active member within your own treatment journey. There have been many studies that have focused on the importance of the therapeutic relationship and ability to give feedback to your therapist. Contrary to some beliefs, therapists cannot read minds. If you have questions regarding aspects of treatment, are unsure if your needs are being met, etc., these are all perfect topics to discuss with your therapist in order to create the most effective treatment. Creating a safe therapeutic space for open and honest communication is often of primary importance to many therapists.

We are all people who at times may feel flawed, but it is important to remember we all are of value! We all can be our own warriors, promote change, and empower others and ourselves. A strong and effective therapeutic journey will assist in allowing you to see you own value. However, it is important to remember that the first step comes down to you, to pull from your internal strength and motivation, to know you are worthy of rediscovering your value.


About the Author: Dr. Whitney Robenolt is a doctoral-level, outpatient, psychotherapist, practicing in Danville, PA.  She currently works as a member of private practice, John G. Kuna, Psy.D. & Associates. She has worked with a wide variety of diverse individuals, including those working towards eating disorder recovery.  She believes the psychotheraputic process is a valuable tool to instill hope, understand one’s value, and making life changes to improve quality of life. She has conducted research on eating disorder etiology and has been a presenter at the Pennsylvania Psychology Association Annual Convention regarding eating disorder treatment modalities. 

About Bulimia

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By: Melissa Gerson, LCSW

Alex starts her day with the intention to “be good.” As she navigates through her day, burdened by negative body thoughts, she feels down but hopeful that she will eat “clean” and with control. By mid-afternoon she’s starving and preoccupied with thoughts about food. When a co-worker puts out a tray of desserts for everyone to partake, Alex tries to resist but then can’t get the treats out of her mind. So she has one. Then another.   She’s on autopilot, out-of-body.   After too many cookies to count she’s despondent, miserable, stuffed.   She purges in the office bathroom since the full feeling is intolerable… and of course, the threat of absorbing all the calories is equally terrifying. Alex is resolved to make this her last binge/purge.   She’s “back on track.” But before you know, a food “mistake” or unexpected temptation gets in the way and the rest is history.

The pattern I just described is the classic bulimic cycle. There is restriction, deprivation, rules about what is on or off limits… Then a temptation, giving in, a food “mistake…” The binge means freedom from the exhausting control – at least for a short while. But then remorse, self-hatred. The purge is supposed to “undo” the binge but at the same time, without realizing it, the purge forgives the binge, actually opening the door for more binges in the future.

Most individuals with bulimia, will relate to some element – if not every element – of this cycle.*   The problem is that intuitively, it seems like more control and restraint are needed. The reality is that the exact opposite is true: over-control, deprivation, rigid rules are to blame. Because of this misguided effort to increase control, many who struggle with bulimia try and try again to end the cyclical pattern but find themselves frustrated in the process – and left with more shame, self-loathing, isolation.

What you should know about bulimia:

  1. Frequent purging – either by self-induced vomiting or laxatives – can lead to dangerous medical complications. The most common concern relates to cardiac health since minerals essential for proper cardiac function like sodium, magnesium, phosphorous get depleted through fluid loss. The only way to know if you have imbalance of these minerals is through a blood test. Your health status can change quickly so frequent labs are essential if purging is happening regularly. You could absolutely be at risk for a serious cardiac event but physically, feel no indication that anything is wrong.
  2. It is so important to consider a behavioral therapy like CBT-E, a treatment designed – and proven – to treat bulimia nervosa. CBT-E is so successful because of its laser focus on the factors that are keeping the cycle going – things like chronic dieting or restriction, rigid food rules (i.e. good and bad foods)… and also factors like intense focus on weight/shape, harsh comparisons to others and body checking like frequent weighing or body checking (mirror, pinching etc).
  3. CBT-E focuses on guiding you to a pattern of regular, consistent and flexible eating – an eating style that tends to reduce one’s vulnerability to binge eating and purging.   The treatment works to change your relationship with food (and thus your control!) by integrating:
    1. Flexibility: encouraging an approach to eating that allows for last minute changes, social eating, managing with the food available to you.
    2. Variety: balanced, satisfying meals. Moving away from having “off limit” foods since those tend to be the very things people consume in excess later.
    3. Adequacy: under-eating, delaying eating for long periods makes you more vulnerable to over-eating. If you’re starving, it’s harder to stay in control.
    4. Awareness: being present, aware of what is happening in the moment is key to maintaining control over eating behavior.
    5. Planning: you mustn’t under-estimate the power of being prepared. For many who struggle with BN, decisions on the fly lead to trouble. We want to move away from impulsive decision-making.
  4. Treatment must also address your current coping strategies since binge eating and purging for many are actually methods for relieving stress, numbing out, escaping….   To recover, you will likely need to establish alternative methods of coping – skills and strategies so you can care for yourself and manage feelings without defaulting to food-related behaviors.

Bulimia: The Bottom Line

There are many factors that contribute to the development of bulimia – biological/genetic, cultural/social, emotional…. But often what caused the problem in the first place is less important to focus on that the factors that are keeping the problem going now.

Bulimia is highly treatable. With the right intervention, people are able to make significant changes very early on in treatment. It is so important to seek help if you’re stuck in a destructive cycle with your eating.

* Please note that every individual is different. The pattern described in this post is among the more common presentations but there are many who have a very different “clinical picture.” Regardless, it’s essential to understand your pattern so that you can target the factors that are keeping it going.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

What’s An Eating Disorder IOP?

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By: Melissa Gerson, LCSW

An Intensive Outpatient Program (IOP) is a treatment option that serves as a step-down from a residential or partial hospitalization program, or a step-up from standard outpatient therapy. IOP is an opportunity for individuals to engage in their daily lives (i.e. participate in work, school or community and social activities) while working toward treatment goals in a supportive and structured environment. For those who are phasing back into their everyday lives after a residential stay or partial hospitalization program, IOP is an opportunity to restore independence. For those who are seeking a higher level of care than a traditional outpatient program, IOP provides more points of contact with a treatment team and peers while enabling participants to participate in the activities of daily life, as appropriate.

What is the time commitment for an Intensive Outpatient Program?

Traditional IOP programs will require between 6-15 hours of treatment per week over the course of 3-5 days. The intensity (i.e. 3 vs 5 days) depends on the individual needs of the client.  Some programs run IOP in the evening hours (5-8pm or 6-9pm) while other programs may offer more flexibility with daytime options for those whose schedules allow.

What does treatment look like on a day to day basis?

IOP is an opportunity for many to “jump start” treatment. In other words, in a short amount of time, programs work to redirect and shape behaviors, change long-standing patterns and support new strategies for stable eating. Typical expectations for an IOP suggest a 50% reduction in symptoms within 8 weeks.  For those who are stepping down from more intensive settings, IOP may be structured differently…. to slowly expose the individual to more and more independence until the client feels confident to move on.

IOP hours typically include group therapy, supported meals, individual therapy and family work (if indicated).  Intervention strategies and objectives vary by disorder. For example, for AN clients, it’s important to see movement toward more varied and balanced eating along with a clear trajectory of weight restoration. With bulimia, an ideal program will focus in on food exposure, variety and skills for managing/coping with urges to binge or purge. For binge eating disorder,  an IOP program would be geared around skill building, developing self-awareness, mindfulness, distress tolerance, and emotion regulation.

To determine if an individual is appropriate for an IOP program, clinics will typically utilize standards established by the American Psychiatric Association.  Below is a basic chart – based on the APA standards – that we use at our Columbus Park IOP.  It represents some factors we consider when establishing the appropriate level of care for individuals coming into our program.

Standard Outpatient CriteriaIntensive Outpatient Program  CriteriaPartial Hospital/Residential/Inpatient Criteria
Medically stable/cleared by Medical DoctorMedically stable/cleared by MD/ frequent follow up requiredMedical instability
With guidance, pt is capable of creating one’s own meal structureExternal structure needed to eat or gain weightSupervision required during/after meals
Fair to good motivation to recoverAt least fair motivation to recoverPoor motivation to recover
Co-morbidities  (i.e. depression, anxiety) may have some limited impact on functioningCo-morbidities (i.e. depression, anxiety) have high impact on functioningPsychiatric condition requiring hospitalization
Suicidality, if present, is passive (no active plan or intent to take one’s life) 

Suicidality, if present, is active and more structure/points of contact needed.  Possible suicide attempts in past.

 

Suicidality is active w/intent and plan and unable to contract for safety
Some ability to control exerciseSome ability to modulate exerciseStructure needed to prevent compulsive exercise
Some social supportLimited social supportNo support available to add structure outside of treatment

 

Could you or a loved one benefit from an IOP program? Most insurance carriers list local facilities that are covered in their networks.  You can either look on your carrier website or call a representative who can walk you through the covered facilities.  It’s also great to search online since most programs will have detailed information on their websites.  You’ll want to get a sense of the overall program philosophy, treatments used, structure and schedule.  Ask for a tour or informational meeting to get more of a sense of the setting.   Be an educated consumer and ask questions.  You have a right to know what you’re getting into even before you go in for an initial assessment.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.

So What is CBT-E?

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By: Melissa Gerson, LCSW

Consistently across research trials, Enhanced Cognitive Behavioral Therapy (CBT-E) is shown to be the most effective treatment for eating disorders in adults. CBT-E is without a doubt the leading intervention for most individuals with Bulimia Nervosa and Binge Eating Disorder.   For adult Anorexia – a more difficult condition to treat once the behaviors have habituated – CBT-E is also shown to be a first line treatment and effective in the majority of cases.

CBT-E is a short-term, time limited, individual outpatient therapy. Patients work one-on-one with their CBT therapist to uncover the factors that keep their eating problem going – and then systematically they together, tackle them in the treatment.

For Bulimia and Binge Eating Disorder, CBT-E treatment consists of 20 treatment sessions over 20 weeks.   For people who are underweight, the treatment tends to be longer (typically 40-sessions over 40 weeks for Anorexia).

CBT-E has four stages. In Stage One, the focus is on fully understanding the factors contributing to and maintaining the individual’s eating struggle. Early on, the therapist works with the client to encourage regular, consistent eating (yes, it’s possible). There is a focus on increasing self-awareness and using problem solving techniques to understand why at times eating goes off track. In this first stage of treatment, it is best to meet twice-weekly. A lot of change should occur during this initial stage of treatment (the first 4 to 8 weeks).

In the brief second stage, the therapist and client review progress together and construct a plan for Stage Three.

Stage Three involves weekly sessions focused on the factors that may be continuing to keep certain eating struggles going. Typically, any intense concern with weight and shape will be addressed thoroughly in this stage of treatment. Dieting and other forms of over-control of food are considered important areas of focus here as well. The therapist will also work with the client to better manage event and mood triggers for disordered eating.

Towards the end of Stage Three and in Stage Four the session shifts attention to the future; specifically, on how to reduce vulnerability to setbacks or relapse in the months and years ahead.

They say that CBT-E should “fit like a glove.” So while it is a manualized and highly structured treatment with very specific strategies and protocols, it is designed to shape itself to each individual’s needs. The attention is always on the client’s unique picture…. on understanding the ins and outs of the individual’s patterns and triggers.

If you are interested in CBT-E, be sure that you seek out providers who practice CBT-E true to its design. Using CBT-E strategies here and then without full fidelity to the model will weaken the treatment. Once you find a provider who practices CBT-E, you can arrange an assessment to see if it is the right treatment for you.


About the Author: Melissa Gerson, LCSW is the Founder and Clinical Director of Columbus Park, Manhattan’s leading outpatient center for the treatment of eating disorders. As a comprehensive outpatient resource for individuals of all ages, they offer individual therapy, targeted groups, daily supported meals and an Intensive Outpatient Program (IOP). Columbus Park uses the most effective, evidence-based treatments like Enhanced CBT and Dialectical Behavior Therapy (DBT) to treat binge eating, emotional eating, bulimia, anorexia and other food or weight-related struggles. They track patient outcomes closely so they can speak concretely about their success in guiding our patients to recovery.