he Emerging Role of Eating Disorder Coaching
By Carolyn Costin, MA, Med, LMFT, CEDS, FAED
“The challenging behaviors of eating disorders are entrenched in daily life, specifically around meal times, and cannot be avoided. Assistance during everyday living can make the difference between recovery or not.” (NEDC, 2017)
Eating disorder coaches are emerging as an adjunct to standard treatment, filling a much-needed gap in traditional services by working in conjunction with the client’s treatment team, assisting with the daily, practical, hands-on aspects of recovery.
Coaches offer services such as, ongoing text support, assistance with meals, grocery and clothes shopping, cooking, attending social functions or even spending time at the client’s home during transitions, such as when leaving inpatient or residential treatment. In essence, coaches can provide support that licensed treatment professionals cannot provide due to time constraints or ethics.
Millie Thomas, an eating disorder coach with EndEd in Australia, thinks of her work as “a missing link,” pointing out that, “Eating Disorders do not just operate within office hours, thus those who are suffering need support outside of regular treatment sessions where they can get guidance and reassurance in ‘real time’ rather than waiting until their next appointment.” Eating disorder coaching is a complement to treatment that has been missing for years and is long overdue. Now that it’s here, it’s important to get it right.
Coaches have existed for years in the field of addiction, mental health, and life skills support, and have helped individuals struggling with a health or well-being issue in many ways. Sober coaches are well known as a major aspect of recovery support for those with addictions. However, in the eating disorder field, coaching has lagged behind and only recently started to surface as a sought after form of support. I have had many conversations with colleagues and given much thought as to why this is true and three major reasons present themselves.
First, many people fear that anyone can claim to be an eating disorder coach, yet they could be unprepared and unskilled to help this population. This concern is well founded since until I opened The Carolyn Costin Institute, there was no training or certification for eating disorder coaches. Deservedly, this has contributed to the overall apprehension about eating disorder coaching.
The second major concern expressed is that many eating disorder coaches have their own personal history of an eating disorder (lived experience) and could still be unwell or might relapse while working as a coach. How does one know when a person is “recovered enough” to become a good coach for others and not be at risk of relapse?
The third concern has been expressed to me in various ways but in summary centers around the fear from eating disorder treatment providers that clients might use a coach instead of a licensed professional. People have suggested that working with individuals who have eating disorders is so difficult and complex that it should be left to licensed professionals. This concern misunderstands coaching and assumes that coaches are doing the same job as the professionals and would not be working with, and as an adjunct to, the licensed team, which coaching is designed to do.
These three main concerns I have heard expressed regarding coaching have delayed the emergence of coaching as an important ancillary support for eating disorder recovery. Despite those expressing apprehension, clients and their families are increasingly seeking out eating disorder coaches to help in the recovery process. Therefore, it is important that concerns are addressed and eating disorder coaching is taken seriously in order to ensure its quality and success.
The first concern, involving skill and training is why I started the Carolyn Costin Institute (CCI) where I now train, supervise and certify eating disorder coaches. When looking for a coach, consumers should look for one who is certified by a reputable course provider. Consumers should check that a coach has taken course work, passed exams, undergone supervision, completed an internship and become certified. A certified coach should also be required to take continuing education to remain certified. *
The confusion that exists as to what a coach is, what a coach does, and how coaches differ from a professional team member or a mentor, contributes to the concern over skill and training. A coach is not a licensed professional and does not diagnose or provide “treatment” or prescribe meal plans. Coaches are trained to focus on helping clients accomplish tasks and change behaviors in the here and now and do not discuss underlying issues or work on the causes of the eating disorder, as that is the job of professionals such as registered dietitians, therapists and psychiatrists. Eating disorder coaches are trained to work with a team specifically helping clients carry out the goals of the team by being in the trenches with clients working on daily recovery tasks. Coaches charge for their services but the rate is less than that of a licensed professional and should allow a client to add the coach as a part of the overall “team.”
A coach is also different from a mentor. Mentors have traditionally been known as individuals who have lived experience, i.e., they suffered themselves from cancer or schizophrenia or an eating disorder, and they volunteer their time to help others suffering from the same affliction. Mentors are minimally trained, if at all, are not certified, and do not charge for their services. Sometimes mentors work for organizations, such as the eating disorder mentors from Project Heal, who get some training and supervision to offer individual or group support but do not eat meals with clients.
The second concern involves the fear that those with their own eating disorder history might not be well enough to do this kind of work. It is important to note that not all eating disorder coaches have lived experience but since many people who wish to become coaches do have their own personal history, I believe it is critical that these individuals declare that they are “recovered” and that they have been recovered for two years. I use my personal definition of “Recovered” taken from page 164 of my book, “8 Keys to recovery From an Eating Disorder.”
Being recovered is when the person can accept his or her natural body size and shape and no longer has a self-destructive relationship with food or exercise. When you are recovered, food and weight take a proper perspective in your life, and what you weigh is not more important than who you are; in fact, actual numbers are of little or no importance at all. When recovered, you will not compromise your health or betray your soul to look a certain way, wear a certain size, or reach a certain number on the scale. When you are recovered, you do not use eating disorder behaviors to deal with, distract from, or cope with other problems.
It is impossible to know when someone is really “recovered” but that holds true in any circumstance where someone with lived experience is helping others, whether a licensed professional or not. People with lived experience are working all the time in professions such as therapists, dietitians, and doctors without ever even revealing their eating disorder history. This, too, has happened in the coaching field and it is important to get ahead of it, allowing individuals to feel safe enough to reveal their lived experience so that we can properly screen and train them if they are going to work in the field. Past eating disorder experience can be a liability or an asset and a first step is requiring some criteria in order to even begin coach training. That is why I ask individuals with lived experience to state if they do, or do not, meet my definition of “recovered” and have met it for two years. It is impossible to know if a recovered individual will relapse but in my 40 years of experience training recovered mentors, coaches, therapists, dietitians and other professionals, I found that 2 years is a good benchmark to require. As Chief Clinical Officer of Monte Nido & Affiliates, requiring individuals, who were seeking employment and revealed they had lived experience, to meet my definition of recovered for two years, greatly contributed to my success in using those who are recovered as part of a treatment team. In 22 year, I had only one staff member relapse and need to leave her position. The other important aspect of successfully using those who are recovered is that any certification process should have additional specific training in how to use ones’ personal lived experience to help optimize using the positive aspects of one’s recovery and avoid pitfalls that can easily occur. For this reason, CCI coach training has a special track for recovered coaches. Olivia Soha, owner of Uncovery in Australia, has stated, “Recovery is often a subjective process that involves a lot of patience and hope. Lived experience is a profound tool that if used appropriately, has the ability to help a coach relate, empathize and connect with clients. Lived experience not only helps us to connect with, and encourage our clients, but shows them that no matter how far away recovery feels, we are living proof that it IS possible.” Research on utilizing those who are recovered as part of a continuum of eating disorder care continues to show it to be an important component of support and recovery.
The third concern is that eating disorder treatment is complex and complicated and coaches should not replace treatment professionals. I agree with this statement and indeed coaches are not a replacement for professional care but rather are there to help in ways that the licensed professionals on the team just can’t or don’t want to do, for example, late night phone calls, setting up a kitchen, or accompanying the client to a restaurant or the gym. A coach is available via call-text-email outside of regular session times, at all hours, allowing clients to reach out when struggling. This ‘in the moment’ support not only provides help at inconvenient times, but also teaches clients the skills of reaching out to people, rather than their eating disorder, which is a key to recovery.
A coach supports the treatment team, works in conjunction with team, and helps the client accomplish the team’s goals. Coaches help carry out the necessary task of exposure and response prevention (ERP) – meaning they are there to progressively expose the client, under a controlled environment, to known triggers such as, eating specific foods, eating in public or eating without purging, and are trained to manage the situation and the anxiety that may occur. At CCI coaches are taught to focus on HOW to help the client deal with the here and now, dealing with specific behaviors and avoiding discussions of the underlying issues or WHY the person has an eating disorder, as that is the territory of trained professionals. This distinction creates a clear boundary. **See the graph at the end of this article for a quick summary of what a coach does and the difference between therapy and coaching.
Kristi Amadio, coach and founder of Recovered Living, in the U.S. explains that coaches follow a “hands-on, handing over and hands off philosophy.” She shares that, “As their life experiences in recovery grow bigger, my role in the client’s lives grows smaller. They venture further away from the coach because they are gaining confidence in their ability to thrive in recovery, no matter what.” In the beginning, coaches will likely need to be very hands-on, being more directive and present while clients test out their recovery skills. Coaches encourage and nudge clients to take critical recovery steps, reassure clients they will be ok, and role model appropriate behavior. As clients begin to gather confidence, they can become more independent and wean off the coach. For example, initially a coach and client might grocery shop together, with the coach right by the client’s side, ensuring the right items are purchased. Further along, the same client might go into the grocery store alone while the coach waits outside for support, if needed. Upon leaving the store, client and coach can discuss the experience, go over the purchases, and make any necessary changes. Coaches eating with clients can help determine when an advanced meal session is in order where they challenge the client by ordering something different from the client, or something that will likely be triggering to the client to see if the client can maintain recovery while facing situations that are likely to happen in real life.
Eating disorder coaches work in a variety of situations and settings and can work in person or virtually. The following are some recent coaching requests: A dietitian sought a coach to help eat meals with a client at school who needed support adding food to her meal plan. A therapist requested a coach to help a client reduce her binging and purging in the hopes of preventing the need for a higher level of care. A family asked for a coach to provide in home support for their loved one who was transitioning from a residential stay in the U.S. to a country where little support existed. These are just a tiny snippet of the varied experiences where coaches can play an important role.
The most extensive and complicated form of coaching involves the live-in experience. Words from coach, Kristi Amadio, help to explain live-in work.
I have been blessed a countless number of times with the experience of being invited into people’s families, their homes, and their inner worlds. The gap from residential treatment or even a partial treatment program to life outside of the treatment bubble is a big jump, no matter how it is done. Too often, the eating disorder will take advantage of this gap and begin to weave its way back into the fabric of daily living.
The analogy I use for being a live-in recovery coach is that of being an elite athlete coach at a training camp. An elite football team has a medical doctor, a sports psychologist, a sports dietitian, and a coach. In recovery, clients have a therapist (sport psychologist), a medical doctor, and an eating disorder dietician but until recently they did not have a coach. I have been an elite athlete and had a coach. My coach was my trainer, then when things were hard, when I had questions, when my technique needed adjusting or when I was lacking motivation, my coach would hold the big picture so I could focus on the moment. My coach was with me in the big moments and in the small. Without my coach, I would not have been an elite athlete. As an eating disorder recovery coach, I am there for the recovery training sessions; the meal and snack times, the grocery shopping, the cooking and the restaurant meals, and even some social outings. I am there when the client’s food portioning needs adjusting. I am there when their self-talk is turning negative and they need some motivation. As an eating disorder recovery coach I hold the big picture of recovery in my mind while breaking down each step of recovery into manageable days, hours, and tasks.
The beauty of a live-in recovery coach is that every training session can be specifically designed for each person, like having a dress tailored specifically for the person’s size and shape. Together we sort through the clients closet, de-clutter their home of potential triggers, and get rid of things like laxatives or diet pills. As a coach, I know the value of every training session adding together to create a solid foundation for success. Liv-in coaching is an incredible recovery opportunity, helping the client stay accountable to recovery, every step of the way. Just as it is for elite athletes, in the game of recovery, every moment counts.
I hope this article helps reduce the concerns surrounding coaching and highlights the important role coaches can play. Utilizing trained, certified coaches, clients can get needed support managing real life situations, families can get help supporting their loved ones, and clinicians can increase their client’s recovery rates by working with a skilled individual who can provide between session follow through to assist with behavior goals.
*For a detailed description of the CCI certification process, readers can visit the Carolyn Costin Institute on line at https://www.carolyn-costin.com/coaching.
