Meal Support Therapy for the Outpatient Population: 6 Options to Explore

By Laura Cipullo, RD, CDE, CEDRD

When dieting has failed, your body has turned off, and your peers’ bodies and plates look different, how do you know what or how to eat? Whether you are stepping down from a higher level of care or need practice using internal hunger fullness cues, there are now outpatient therapeutic meal options supports to expose, teach, and/or support learning to eat. There is even research supporting the effectiveness of some of these therapeutic options that include exposure therapy specifically for individuals diagnosed with anorexia1 and mindfulness for clients with binge eating disorder.2 The meal support sessions can be in the form of an individual session, a group, or with a companion. Meals can be offered in different environments, whether in day treatment at an eating disorder facility, in the office during a session, or even at a restaurant. Meal support therapy is often times co-led inpatient by an RD and a LCSW or psychologist. However, in the outpatient setting, it’s typically one or the other for a number of reasons—including state laws. So how does one know what type of meal support system to choose or from what kind of leader they would benefit?

There are multiple modalities for eating therapy, including a self-attuned model, intuitive eating model, family-based model, mindful model, and traditional model. This article will discuss the different types of supportive meals and the strengths and weaknesses of each. There is no right answer or no right group. Each individual must determine what is best for his/her personal situation and what will be most beneficial now as well as in the future.

Self-Attuned Eating Group

Self-attuned eating stems from a feminist psychoeducational and psychodynamic model. Andrea Gitter, MA, LCAT, BC-DMT, of the Women’s Therapy Center Institute, relates it to “fine tuning one’s response to physiological hunger and satiation.” She shared that both women and men have the opportunity to get in touch with these states of body and mind “to allow one to become more emotionally literate, to be able to identify and challenge cultural mandates and develop a more integrated body/psyche/self.” The self-attuned model can be taught individually or in a group setting by a licensed mental health professional. Clients do not eat in these sessions; they are purely didactic. This is a great option for both women and men who have been failed by diets or have been unsuccessful in changing their relationship with their bodies. This body based approach does consider medical conditions and will refer to the dietitian for medical nutrition therapy as determined by the licensed mental health professional.

Strengths:

1. Helps to heal the relationship to food, eating, and the body/self
2. Can change obsessive/compulsive thoughts and behaviors in regard to food, eating, and the body/self
3. Promotes self-esteem and self-agency (because the person is the expert at determining her internal cues on what and when to eat)
4. Empowers women and their bodies
5. Is anti-diet

Weaknesses:

1. Requires time and patience
2. Misses the aspects of medical nutrition
3. Not appropriate for many clients with acute eating disorders; better suited for those with emotional eating or a history of yoyo dieting
4. Does not include meals
5. Does not include exposure therapy to “binge” or “unsafe” foods

From the WTCI website3:

“The self-attuned model introduces curiosity and compassion as alternatives to the punitive and restrictive methods women typically employ in their efforts to change their relationships with food and their bodies. Next, the group focuses on legalizing all foods and eliminating dichotomous thinking about food, such as good and bad, healthy and unhealthy, or permitted and forbidden food groups. Finally, the group addresses issues of body image and embodiment, including the symbolic meaning of fat and thin and how one’s ideas about and experiences of one’s body function psychologically, interpersonally, and culturally.”

Intuitive Eating Group

Intuitive eating is an approach that teaches you how to create a healthy relationship with your food, mind, and body—where you ultimately become the expert of your own body. You learn how to distinguish between physical and emotional feelings and gain a sense of body wisdom. It’s also a process of making peace with food—so you no longer have constant “food worry” thoughts. You begin to realize that health and your worth as a person do not change because you ate a so-called “bad” or “fattening” food.4 There are groups utilizing an approach based on IE principles; however, this is only appropriate for nourished individuals or those with access to their hunger and fullness cues. Intuitive eating recognizes that not everyone is ready or able to identify his/her inner cues and recommends “nutrition rehabilitation” under the care of a RD to assist in readying an individual.5  Mary Dye, MPH, RDN, CEDRD, CDN, LD/N, and nutrition director of Oliver Pyatt Center (a residential and transitional treatment facility) says, “we use an IE model however, in reality it is truly mindful eating we are teaching. We fully plate and expect 100% completion of the RD prescribed meals until the individuals are at 90% of their goal body weight and medically stable. We remind them that they are mindful eaters and with that comes eating when not hungry at times and eating past fullness at times (for instance needing a snack but not feeling hunger for it or needing to eat past fullness to meet needs in a meal). In meal support, we give feedback that is general, such as ‘you’re about right’ or ‘you need more.’ We don’t give specifics like ‘you need three more spoonfuls,’ we keep it broader to challenge them to check in with themselves and see if they can tolerate this non-specific style of directives.”

Strengths:

1. There are no labeled foods, hence no need for guilt
2. Employs a “Gentle Nutrition” model
3. Recognizes the need for “nutrition rehabilitation” before engaging in the IE model of body trust
4. Can be adapted for children and adults
5. Based on internal self-regulation

Weaknesses:

1. Difficult to read hunger and fullness cues
2. Hunger and fullness cues may be deregulated in a small percent of the population due to foods, blood sugar fluctuations, and hormonal changes
3. If trying this in a meal support group, clients may have different levels of hunger and fullness at the time of the group
4. Clients must determine the difference in emotional, behavioral, and physical hunger
5. Clients can be triggered by other clients’ amount of food eaten
6. Clients must be adequately nourished to use a true IE model.

Mindful Meal Support Therapy Group

With research-based evidenced supporting its effectiveness, especially in clients with type 2 diabetes6, mindful eating has been added to the list of meal therapies. Mindful meal groups typically start and finish with meditation. The purpose of this meditation is to first separate the chaos of the day from the act of eating a meal and to recognize when one is eating. Recognizing the act of eating helps to make a meal psychologically satisfying and also helps clients get in touch with the internal regulation system (aka hunger/fullness cues) and/or emotional hunger and fullness.

Mindful eating groups are a great way to practice what is taught in many nutrition sessions. Practicing mindful skills can also be used as a tool to decrease anxiety, increase body trust, and prevent fear of overeating and or binge eating. Clients in need of re-nourishing their bodies as well as those who are adequately nourished can employ mindful eating. After a mindful exercise when the individual recognizes his/her body’s state and is aware he/she is about to eat, the facilitator can help the clients use their five senses in their first bites. Again, this is to help the client learn these skills so that he/she can engage them on his/her own. With mindful eating, clients must eat even if they feel emotionally full or cannot tell what they feel because they understand that they physically need food. The RD can help the client in determining an “appropriate” amount of food when eating out at a restaurant. Eating in this outpatient setting helps clients learn to navigate menus, eat all foods, eat appetizers, entrees, and dessert at one mealtime, and not engage in symptoms. In an ideal outpatient environment, the LCSW, PhD, or PsyD would be present to help clients process their feelings before and after the meals.

Strengths:

1. Can be appropriate for different states of nutrition
2. Best if led by the LCSW and RD together
3. Teaches mindfulness before, during, and after the meal
4. Offers process time before and after meals
5. Depending on the facilitator, teaches “all foods fit” model

Weaknesses:

1. No certification for the facilitator teaching mindful practices
2. Clients can be triggered by other clients’ percent of meal eaten as this differs for each client
3. Can only be led by RD for undernourished clients in restaurant environment as portions are not predetermined
4. Ideal to have both RD and LCSW or PsyD/PhD co-lead
5. Often gets confused with Intuitive Eating

Traditional Meal Support Therapy Group

The original meal support therapy was part of the daily feeding environment provided in a higher level of care such as residential and/or partial hospitalization. As an extension of day treatment and intensive outpatient, MST began to be offered in isolation like any other outpatient group. In this traditional group, ideally both the therapist and a registered dietitian co-lead the meal. However, due to private practice legal constraints, many centers and practices now only offer either a therapist or an RD, but not both. Clients are given a standard meal with snacks or supplements depending on their individual nutritional needs. All clients are expected to complete 100 percent of their meals. “RDs are uniquely qualified to lead clients into a conversation exploring their internal regulators of eating including both physiological and psychological cues of hunger, fullness, appetite and satiety. Completing 100% of the meal is a very important guideline for clients to follow, particularly at the beginning of their treatment when hunger and fullness cues are functioning improperly and cannot be trusted,” said Laura Bennet, RD, of NYC. Bennet also stresses the importance of finishing the entire meal, “down to the last bite,” in order to challenge the rigidity and disordered thoughts of the eating disorder. When asked about the specific role of the RD at meal group, Laura shared, “RDs are often educated on food rituals (used to alleviate anxiety during a meal such as taking very small bites) and can provide the necessary redirection to keep the client feeling supported and on target.” These meals are typically offered continually, with the client’s coming and going based on the client and multi-disciplinary team’s decision. These meals typically last an hour and involve a pre- and post-meal check in and goal setting.

Strengths:

1. Offers an educational and supportive environment
2. Ensures client gets in one adequate meal daily
3. 100 percent meal completion prevents restriction
4. One-hour limits prevent deliberate delaying and/or lengthening of meals
5. RDs can provide nutrition education (for example, the need to eat carbohydrates for fueling the brain, which only uses glucose)
6. Therapists can help process fears related to feelings of emotional fullness

Weaknesses:

1. Eating in the company of others with eating disorders can provide an environment for comparing food intake and body size
2. Clients with high anxiety have the potential for panic attacks
3. One meal a day is not sufficient for adequate nutrition
4. Clients may refuse meals and trigger other clients
5. Client has the potential to use symptoms before and after the meal

Family Meal Support

Family meal support is used to help an individual of any age with an eating disorder (most evidence based on anorexia) consume an adequate amount of nutrition. “The family dynamic must be cohesive, stable and supportive,” says Stephanie Jacobs, LMHC. This individual must live with their family as the family and/or caregivers become the “feeders.” They are in charge of preparing, serving, and supervising meals in the home setting (or restaurant). The caregivers are always present to ensure that their child is able to eat their meal and/or snack. Mount Sinai’s Eating and Weight Disorders Program is well known for teaching and providing this type of meal support in the context of family therapy (Maudsley method) sessions. FMS expert Dr. Terri Bacow says, “Parents and or caregivers are to provide support and coaching to enable the child to eat. The caregiver may provide a blend of empathetic encouragement as well as firmness, telling the child that s/he may not want to eat, but really needs to do so. The parent/caregiver may remind the child that it is okay to want to avoid finishing a meal or eat certain foods, but that this is important for health.”

The following strengths and weaknesses (1-4) on Family Meal Support come directly from Stephanie Jacobs, LMHC, of the Mount Sinai Eating and Weight Program.

Strengths:

1. Creates/enhances a supportive environment to help the child eat and let others know the meal was finished
2. Healthy way to connect with family and share information outside eating issues (i.e. school, friends, trivia), which can lead to a stronger sense of family unity (i.e. bonding)
3. Can be a key way of distracting person from preoccupation with food, weight, and/or shape
4. Can provide a productive pressure to eat/finish healthy amount of food
5. Opportunity for others to model and normalize healthy eating behaviors

Weaknesses:

1. If the person is only triggered by peers, in which case family meal support may be helpful, but not enough to help the person get used to eating healthily with peers/others
2. If the family dynamic/system is in turmoil (i.e. high negatively expressed emotion, parents fighting, distressed sibling relationships), this can lead to more distress
3. If the person has demonstrated that he/she is capable of eating on his/her own and experiences the meal support process in itself as condescending/infantilizing
4. If person uses meal support in a destructive way (i.e. suggests or acts in a way that may cause harm to self, others, or property), in which case a higher level of care may be necessary
5. Medical nutrition therapy is not typically part of this model.

Meal Companion

The concept of eating with clients in a one-on-one environment became popular in 1995 when Ellyn Satter, RD, LCSW, first introduced the practice of eating with clients in session to teach eating competence. Since then, it has become a norm for dietitians and therapists to follow Ellyn’s example. I can attest to the value of Ellyn’s teachings in both her three-day workshop and manual called Treating the Dieting Casualty. It has since been taken outside of the office and into restaurants.

Many eating disorder specialists such as registered dietitians have been eating with their clients as part of a session or extension of a session for years. This allows the practitioner to identify food rituals, encourage food consumption, and promote accountability. This can also be an opportunity for a therapist to discuss emotional fullness and/or help clients with a history of trauma work through feelings brought on by taking in food.

Like a sober coach, there are now professionals (beyond the typical team) offering meal services in a one-on-one environment. This enables an individual to be accountable to an objective and trained coach or licensed health professional who can then share the individual’s progress with the team. These services are similar to a concierge service. Greta Gleissner, psychotherapist and co-founder of Eating Disorder Recovery Specialists, said, “our services are best utilized as an adjunctive support for clients who are stepping down in levels of care, or who are struggling in current outpatient level of care but want or need to stay in their environment.”

Strengths:

1. Offers client accountability for meals
2. Lessens anxiety surrounding meal time decisions for client
3. Companion can provide objective feedback to the team on food rituals and amount consumed at meals; no personal bias in food intake
4. Well received by individuals transitioning from an inpatient stay to triggers and daily life
5. Many coaches are training/trained to be LCSWs, RDs, or are in recovery
6. Can provide in-home support such as cooking meals with clients

Weaknesses:

1. Can cause splitting if coach does not communicate with team regularly
2. Does not eliminate need for multidisciplinary team
3. Difficult for clients to establish system of trust and safety eating in restaurants with a coach they have just met
4. Client may be too engaged in symptoms and too malnourished for the services to beneficial
5. Coaches/companions need to be trained, and there is no formal training available to date

Each meal support option has its strengths and weaknesses. Talk with your team to determine which method may suit yourself or your client the best. One individual could potentially start with one method such as family meal support and eventually progress to a mindful group with peers. Refer to www.iaedp.com to find professionals certified as eating disorder specialists (CEDS, CEDRD, CEDRN) and www.NEDA.com for free information on eating disorders.

About the author -

A Registered Dietitian, Certified Diabetes Educator and Certified Eating Disorder Registered Dietitian,Laura maintains her private nutrition practice in NYC with over 15 years of experience while specializing in child/adult prevention and treatment of eating disorders.

Laura is the author of “Healthy Habits”—an 8-week-long children’s program educating adults on how to teach children about nutrition and health with a positive, weight neutral approach. Laura founded and manages a blog platform called Mom Dishes It Out for RD moms to share a positive feeding and eating approach. Most recently, Laura authored a continuing education article on the BMI Controversy for Today’s Dietitian.

She is President of the New York chapter of the International Association of Eating Disorder Professionals (iaedp) for her second term. She is a frequent guest on national TV, a public speaker and author of 2 published books.

www.LauraCipulloLLC.com

References -

1. Albano A .M., Glasofer D., Steinglass J., et al. “Rationale for the Application of Exposure and Response Prevention to the Treatment of Anorexia Nervosa.” Int J Eat Disord 44, no. 2 (March 2011):134–41. doi: 10.1002/eat.20784.
2. Corsica J., Hood M., Katterman S., Kleinman B., and Nackers L. “Mindfulness Meditation as an Intervention for Binge Eating, Emotional Eating, and Weight Loss: A Systematic Review. Eat Behav 15, no. 2 (April 2014): 197– 204. doi: 10.1016/j.eatbeh.2014.01.005.
3. Groups for Eating and Body Image Problems. The Women’s Therapy Center Institute Website. http://www.wtci-nyc.org/page4/page4.html. Accessed March 21, 2015.
4. Tribole E. “Intuitive Eating Resources.” 2007–2009. http://www.evelyntribole.com/resources/intuitive-eating-articles-studies-support-groups. Accessed March 20, 2015.
5. Tribole E. “Intuitive Eating in the Treatment of Eating Disorders: The Journey of Attunement.” Perspectives 2010. http://www.evelyntribole.com/uploads/Tribole.IntuitiveEating.Eating%20Disorders.2010.pdf. Accessed March 20, 2015.
6. Corsica J., Hood M., Katterman S., Kleinman B., and Nackers L. “Mindfulness Meditation as an Intervention for Binge Eating, Emotional Eating, and Weight Loss: A Systematic Review. Eat Behav 15, no. 2 (April 2014): 197– 204. doi: 10.1016/j.eatbeh.2014.01.005.