Tuesday, December 1, 2020

Unwanted Effects of COVID-19: Eating Disorders


Unwanted Effects of COVID-19: Eating Disorders

By Kerrie Leonard, PhD Student & Dr. Elizabeth Blodgett Salafia

Appreciation for medical professionals took on a new, special meaning this year as the world dealt with the coronavirus (COVID-19) pandemic. Nurses, doctors, and other important medical professionals have been critical in the frontlines battling the virus. Their efforts are being recognized and praised as many hospitals were filled to capacity and healthcare workers worked tirelessly to help others. The current priority of every healthcare professional is treating COVID-19 patients, but they may not be thinking of another harm as a result of this pandemic: eating disorder relapses and increased disordered eating behaviors. During this time as well as beyond the pandemic, healthcare professionals need to be cognizant of how the pandemic may be harming those clinically diagnosed with an eating disorder and the increased disordered eating behaviors among non-clinical individuals. The COVID-19 virus is not directly related to food, but inadvertently the pandemic may affect or trigger harmful eating behaviors.

One trigger for disordered eating which is relevant right now is the scarcity mindset, or the feelings of resources being scarce. We have seen empty shelves at grocery stores and people hoarding goods and supplies. Although there is no real food shortage in the United States, it feels as though food is scarce. This can create anxiety in those with or without eating disorders, leading to hoarding food, binging, or restricting food intake. Indeed, there is a connection between food insecurity and eating disorder pathology, such that the more food insecure someone is, the higher levels of binge eating, and other disordered eating behaviors occur (Becker, Middlemass, Taylor, Johnson, & Gomex, 2017). Disrupted schedules, pressure to eat healthily, pressure to cook more meals at home, and worrying over food can also be triggering during this time.

The COVID-19 pandemic has been a traumatic experience for many people; young and old; students and working adults; people of color (POC) and non-POC. However, it is important to note that the trauma experienced may not be equal among all. Trauma is closely intertwined with eating disorders: rates of eating disorders are significantly higher in those who have experienced trauma and post-traumatic stress disorder (PTSD) (Mitchell, Mazzeo, Schlesinger, Brewerton, & Smith, 2012). Also, higher food insecurity is associated with higher levels of traumatic exposure (Becker et al., 2018). Various types of trauma are related to the development of eating disorders, including food deprivation, physical assault, emotional abuse, sexual abuse, bullying, etc. (Brewerton, 2007). Firsthand experiences of trauma are not the only link to eating disorders—even seeing internet and television news coverage of distant traumatic events has been shown to be associated with disordered eating (Rodgers, Franko, Brunet, Herbert, & Bui, 2012). The underlying mechanism linking traumatic events to eating disorders is still slightly unclear, but it is known that trauma disrupts the nervous system. In turn, individuals may find it difficult to regulate their emotions which may lead them to disordered eating behaviors as a coping method (National Eating Disorders Awareness (NEDA), 2018).

Further, current pregnant mothers living through the COVID-19 pandemic may unintentionally put their child at risk for later developing an eating disorder. Favaro et al. (2011) found that in utero exposure to virus infections (e.g., influenza, chickenpox, rubella, and measles) between 1970 and 1984 were associated with an increased risk of developing anorexia nervosa. Additionally, St-Hilaire (2015) found that pregnant mothers’ stress as a result of exposure to a natural disaster (e.g., 1998 Quebec Ice Storm) was associated with their child’s disordered eating behaviors in early adolescence. The stress of the COVID-19 pandemic on pregnant mothers can lead to negative outcomes later for their children, although results of those studies may not be generalizable to the current event.

As we may see a spike in disordered eating behaviors and relapses of eating disorders during this time, it is important to highlight that many physicians may feel underequipped to deal with patients who have disordered eating symptomology. In a 2010 study, 78% of family physicians reported having patients with an eating disorder yet felt uncertain about how to treat them (Linville et al., 2010). Also, a review found that medical professionals held negative attitudes towards eating disorder patients (Thompson-Brenner, Satir, Franko, & Herzog, 2012). Further, when race/ethnicity or gender is added into the equation, POC, men, or transgender individuals may receive even less attention because eating disorders are commonly viewed as a White women’s issue. Now, more than ever, we need medical professionals to be knowledgeable and mindful of eating disorders and include disordered eating in their assessments during this time and beyond. Similarly, it is necessary for medical professionals to participate in trauma-informed care. Even as life is slowly returning to the way it was, the unwanted effects of the pandemic can last for much longer. Although the battle against COVID-19 may be subsiding, the fight against the repercussions will continue on.

About the authors:

Kerrie Leonard, is a PhD Student, Developmental Science,Human Development and Family Science, at North Dakota State University.

Elizabeth Blodgett Salafia, PhD, is a professor at North Dakota State University, with research interests in Family and peer influences on adolescents disordered eating attitudes and behaviors.

Tuesday, September 15, 2020

The Emerging Role of Eating Disorder Coaching


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.

Eating Disorders and COVID-19: How Families and Healthcare Providers Can Save Lives


Eating Disorders and COVID-19: How Families and Healthcare Providers Can Save Lives 

By Anna Tanner, MD, FAAP, FSAHM, CEDS

Every year, eating disorder treatment centers across the country experience a significant uptick in phone calls during summer vacation and following the holidays, from parents who are worried their child may be struggling with an eating disorder. As a pediatrician who works with children and adolescents with complicated eating disorders, and a parent of two college students, I understand why this cycle occurs year after year. Parents can more easily observe disordered eating behaviors when their children are spending more time at home.

Similarly, our current social distancing measures and shelter-in-place orders have had a disruptive impact on our everyday lives. Many parents with younger children and adolescents are spending significantly more time inside the house together. Young adults are navigating a new normal that finds themselves unexpectedly sharing a living space and spending additional time with their families.

As a healthcare provider, I believe, now more than ever, in the importance of accessing the right level of care at the right time—especially for eating disorders, which are one of the most lethal mental illnesses. Eating disorders thrive in isolation, and the stress of quarantine is exacerbating disordered eating behaviors for people across the country. It is critical for families—and healthcare providers—to work together to proactively identify worsening symptoms and take action when needed.

Collaboration between families and healthcare providers can save lives, but what does it look like in practice amidst the COVID-19 pandemic?

Bridging the COVID-19 isolation gap—together 

As part of global efforts to stop the spread of COVID-19, many therapists, primary care doctors, dietitians, and other healthcare providers have transitioned to telehealth sessions with their patients. These virtual platforms offer a number of benefits beyond containment and allow us to remain connected with our patients.

That said, it is important for healthcare providers and families to understand the limitations of these platforms. Telehealth appointments are not equivalent to in-person evaluations, particularly for assessing patients with eating disorders who are also coping with the stress of isolation during the COVID-19 crisis. Therefore, there may be times when an in-person visit is required to obtain lab work, assess vitals, and/or complete a comprehensive multidisciplinary assessment.

When using telehealth, healthcare providers can rely on their ability to discern obvious physical signs of engaging in eating disorder behaviors and ask specific questions about new or worsening symptoms. However, healthcare providers and families alike should note eating disorders thrive in isolation and darkness, and make concerted efforts to notice the warning signs during this period of social distancing.

Elevating the role of family and loved ones during a crisis

During a pandemic or crisis, there is no time to wait and see if worsening eating disorders symptoms improve. It is critical for healthcare providers to take the observations and concerns of family members seriously because many patients are medically unstable and require immediate intervention. Very often, these observations and concerns indicate a need for a higher level of care.

Patients with eating disorders tend to lack insight into the severity of their behaviors. However, observations from family members and communities of support can play a vital role in early diagnosis, assessment, and referral to the appropriate level of care.

Families concerned about worsening symptoms should immediately alert healthcare providers if they notice behaviors such as: a preoccupation with food or weight, an obsession with calories or nutrition, constant dieting, rapid unexplained weight loss or weight gain, use of laxatives or diet pills, compulsive exercising, making excuses to get out of eating, avoiding situations that involve food, going to the bathroom right after meals, eating alone or in secret, and hiding food or food wrappers.

It’s also important for healthcare providers to lower their threshold and understand the critical need for referring patients with eating disorders to a higher level of care at the right time. Delays in receiving the appropriate level of care can have lasting medical and physical consequences. Early intervention is critical. Eating disorders can be lethal and complications may be irreversible, particularly for children and adolescents.

Accessing a higher level of care during a pandemic

Understandably, patients and their families may have concerns about seeking treatment outside of the home right now. However, referrals to inpatient or residential eating disorder treatment programs can help patients and families potentially avoid entering a general adult or pediatric hospital. Specialized centers that have transitioned intensive outpatient and partial hospitalization programs to virtual platforms may also be a viable option, depending on the needs of the individual patient. By directing patients to a healthcare system that specializes in treating eating disorders, healthcare providers can limit potential exposure and preserve the resources hospitals need to manage COVID-19.

During these difficult times, it’s important for healthcare providers and families to support individuals struggling with or recovering from eating disorders. Healthcare providers must remember the complications of these illnesses and hold our patients to the medical standards we have worked so hard to establish. Continue to stay connected to your patients. Help them, and their families, overcome the fear and barriers that can delay life-saving treatment. Practice the same self-care behaviors you recommend to patients and their families. When you are worried, listen to your gut.

These same principles apply to family members as well. Communicate your worries with the healthcare providers on your loved one’s care team. Remember, you are not to blame. Eating disorders are not a choice and parents and family members are not to blame and can play an important role in their loved one’s recovery. There is a path to recovery for people living with eating disorders—even in a crisis—but it requires support from a team of specialized healthcare professionals. Reaching out is an act of bravery. You are not alone—and together, we are stronger.

The ACT Matrix


The ACT Matrix

By Jacob Martinez, MA, LPC

A colleague of mine uses a metaphor about a behavior that I love. He speaks of how we often view making choices about our lives as if we were in a buffet line able to walk around leisurely saying to ourselves “Oooh I’ll have a little of that,” or “Hmm, maybe next time.” When in reality of course life moves so quickly that we don’t get those chances to consider every available option. In hindsight it’s always easy to see what we could have done differently and when. No, making choices for ourselves in any given moment is not mechanistic, it’s not a buffet line, and it’s often not clear. Rather, making choices that are meaningful, healthy, and true to who we are is a process of constant conversation with our self. That’s where the ACT Matrix comes in.

The ACT Matrix is a tool and approach to Acceptance & Commitment Therapy that fosters psychological flexibility, the ability to choose what matters in any given moment, even in the face of distressing emotions, thoughts, and memories (Polk et al., 2016). It’s a way of analyzing the function of our behavior, and by doing shining a light on what governs our actions. How many of our actions are driven by the need to avoid, get away from, or control uncomfortable inner experience? How many are driven by seeking to connect with what matters most? How much of our time is devoted to trying to move away from what we don’t want, and how much is devoted to moving toward what we value?

The concept is simple, two intersecting lines and a circle form a graphical interface for relating to your sense of self. Four questions asked repeatedly become an internal conversation about who and what matters in the present moment, what experiences are showing up, and what you can do externally with your hands, feet, voice, time, and energy.

Why not take some time to have this conversation with yourself now, right here? Let’s start in the bottom right-hand corner of the diagram. Think about your life as it stands today, and ask yourself this question: Who and what are important to me?

Your answers can be long or short, simple or complex. They can include people, places, things, and intangibles, like ideals, qualities, or concepts that you value.

When you are finished, sit with those for a moment, and notice how these things have played a part in your life. Think about what it would be like to lose these things or to be disconnected from them. What damage would that do to you?

Next, move to the bottom left quadrant, and answer this question: What inner stuff (thoughts, feelings, memories, etc.) have shown up to get in the way of the things that are important to you? These can be anything, from individual thoughts (“I’m not good enough”) to feelings (anxiety, hopelessness, fear), to memories of past difficulty.

In the top left quadrant: What do you tend to do when that inner stuff shows up? Think carefully about how you have responded to the items you placed in the box below. What have you done when you were under the influence of these thoughts, feelings, and memories? You may have noticed yourself withdrawing, shutting down, sabotaging yourself or others, giving up. I have done all of these things myself.

Maybe you’ve noticed yourself restricting, burning, binging, or any number of other actions. No matter the form, all of these actions are similar in function. They’re designed (in theory) to help you “get away from” some unwanted or unpleasant experience. We call them Away Moves.

After you have listed yours consider what has shown up on the inside for you afterwards in terms of thoughts or feelings. Are the things you wrote in the bottom left box extinguished after you take the actions you just listed, or do they come back stronger? Do other old friends like guilt, regret, or shame show up too? And if so, what do you tend to do on the outside?

Can you see a cycle forming? We call these Stuck Loops, they happen to everybody on earth at one point or another, they’re a natural consequence of our developed mind which responds to our own inner experience just as well as it responds to any external stimuli. The only difference is we can effectively get away from things that are outside of our body. When we try to run away from our inner experience, no matter how far we go we find it there waiting for us when we arrive.

Now finally, move to the upper right-hand quadrant. Here the question is simple. What can you do that would move you toward the person you want to be and the things that matter in your life? Be careful! This is not “What can I do instead of all those Away Moves?” It’s simply, what can I do that would move me toward what matters. Let the question be that simple. If you value certain people, places, concepts, what is the next thing you can do to move yourself toward them no matter how small? If you value certain characteristics about yourself, what is the next thing you can do, no matter how small, to embody those? And what would it feel like if you could? We call these Toward Moves because they move you toward what matters to you.

In the center of your grid, draw a circle that connects all four boxes and consider the following questions. Who is the person who gets to decide who & what are important to you? Who is the person who experiences all of that inner stuff that gets in the way of living the life you want, even when nobody else is aware of it? Who is the person who does have control over your hands, your feet, your voice, your actions?

YOU! There is a You there at the center of your life. Go ahead and write “ME!” really big inside that circle. If you’ve come this far, right now at this very moment, you are connected to YOU. You have the power to decide what to do in this moment.

The ACT Matrix is fundamentally just a set of questions that you ask of yourself, over and over. A conversation that lasts forever, but one you’re glad to have. When this conversation is an active one, we move into a psychologically flexible stance, and are better able to exert some level of control over what we once saw as insurmountable. We can more effectively learn from our thoughts and feelings and engage in actions that move us toward a more meaningful life, we can break out of that stuck loop!

Allow yourself to ponder these questions from time to time, and notice what happens when you have this conversation on a regular basis.

Shades of Grey – Ethics in the Treatment of Eating Disorders


Shades of Grey – Ethics in the Treatment of Eating Disorders

By Kendra Wilson, MSW, LCSW, CEDS-S, DBTC 

The journey towards recovery can take many forms, but every person has to follow their own path towards health and make choices along the way. Some of these choices may come in the form of different treatment centers or levels of care to address the difficulties someone is having at that stage of their recovery. Every person’s process is different. There are several ethical decisions that need to be made in the course of care, by both the treatment team and the client, that may not be obvious at first.

“Levels of Care” in Eating Disorder Treatment – an Overview

Eating disorders are very complex illnesses that require specialists to treat not only the emotional and behavioral facets of an illness, but the medical one as well. For these reasons, the American Psychological Association (APA) established guidelines for appropriate levels of care with eating disorders. To see the full APA criteria for eating disorders, click here. This is the first level of ethical considerations when deciding what kind of care someone with an eating disorder needs.

Usually, these difficult conversations start when we, as clinicians, recommend a higher level of care for someone who we do not think is appropriate for outpatient or Intensive Outpatient Program (IOP) treatment (the services we provide at our center – Chyrsalis Center, NC). To be appropriate for outpatient or IOP, a person must be:

  • Medically and psychologically stable to the point they are not a danger to themselves or others
  • Motivated to recover
  • Cooperative
  • Self-sufficient
  • Able to control their thoughts and behaviors using appropriate social support

When someone needs a higher level of care, they are usually:

  • Medically compromised (by weight, bloodwork, EKG, etc.)
  • Unable to manage their behavior
  • Un- or under-motivated
  • Not functioning in their lives in some significant way (work, family, relationships, etc.)
  • Unable to manage a co-morbid condition (psychological or medical) because of their eating disorder

Levels of care indicate how much structure, support, and observation a client requires at that stage in their recovery.


When someone needs a higher level of care, it can be a very difficult discussion between provider and client. Sometimes, we all know it is coming and have been trying to avoid hospitalization but it just is not working. Other times, clients may take a sudden turn. This could be for many reasons, but the important thing is that clients get the help they need to recover from their eating disorder and co-occurring disorders. Our goal is always to help our clients and keep them focused on living healthy and productive lives, and we try to balance all their individual needs while keeping the goal of a full recovery foremost in our minds.

It is important to use the right tool to complete a task, and sometimes that tool needs to be a higher level of care in order for someone to truly recover. Often, hospital and residential levels of care can get clients back on track faster than outpatient could and sometimes that is necessary for someone’s well-being or even survival. PHP and IOP levels can provide support to keep someone out of the hospital or they can provide support as a step-down program. The transition between inpatient and home can be very stressful and there are a lot of facets to consider including social, family, academic, or work stressors. All of these are affected by or contribute to eating disorder behavior. A person cannot live in a vacuum, so all of these need to be managed before someone goes back to their regularly scheduled lives.

Multi-Disciplinary Treatment Teams

The standard of care in all levels of treatment includes a multi-disciplinary team with a therapist, dietitian, medical, and psychiatric doctor at a minimum. The team can also include various medical and mental health specialists (for example a GI doctor or a family therapist), and the client’s support system, to encompass all the concerns for the client.

In eating disorder care, not having a dietitian or a medical doctor on board and in regular communication with the therapist is unethical. It is the equivalent of having a missing member of a surgical team, like not having a nurse or an anesthetist. It is not safe for the client, no matter what the client may believe. There are times when the makeup of the treatment team may change – perhaps the client is not on psychiatric medications or they have been medically stable for a significant period of time and no longer go in to see a member of their medical team regularly – but it is not just who is on the team that is important. It is also that the team communicates effectively, which usually means the team has a leader. This is most often the primary individual therapist, as this is the person who usually sees the client the most. As a team leader, it is your job to coordinate the rest of the team, even when there is resistance. Your job is also, usually, to be the eating disorder expert on the team – if you are not an expert, you will need to get supervision from someone who is, even if they are in another discipline.

You cannot effectively treat a client with an eating disorder without the information these specialties provide, but the same is true when the team does not function. This requires leadership, regular communication, and an awareness of the pitfalls inherent in this population. “Splitting” or the dividing of the team by the client, family, or another team member that does not allow them to communicate effectively, is one cause of discord. An example of splitting would be when someone goes to one member of the team to ask for something but doesn’t like the answer, so they go to someone else to ask again. The key to managing splitting behavior is constant communication and clarity about the fact that team members communicate frequently.

Another aspect of a healthy treatment team is a cohesive treatment style and methodology amongst the team members. This is easiest if you work in a team and have regular team meetings, but can also be around using a similar style, language, or method – like Dialectical Behavior Therapy (DBT) – to communicate concepts to the client.  Other tools, like treatment agreements or contracts, also need to be shared amongst all team members and clarified so everyone is giving the same message to the client.

Things can get very confusing if the therapist or psychiatrist give nutrition guidance, or the medical doctor contradicts the therapist. Though this unfortunately happens, we all need to be aware of our strengths and limitations on the team so we can make sure the client is talking to the best person to answer their questions and the client gets consistent information. The last thing any treatment provider wants to do is block a client getting the care they need, so we all need to “stay in our lanes.” Sometimes, we need to think about our motivations for helping, and also, to make sure the best interests of the client are the primary consideration.

Finally, resources are sometimes not available. This may mean you are working with team members who have little or no eating disorder treatment experience, or there are no providers, at all, in your area. Again, this is when supervision and consultation are the most useful and ethical things you can do. To get consultation or supervision for eating disorder treatment, the best option is the International Association of Eating Disorder Professionals (IAEDP), who have lists of supervisors and consultants around the world.

Other Barriers to Treatment

Aside from building and maintaining an effective team, there are a number of other barriers to treatment. One of the biggest is financial or insurance limitations on care. Despite parity laws, sometimes nutrition benefits for eating disorder treatment or even higher level of care are not covered by insurance or the client doesn’t have means to get the treatment they need. This is an unfortunate and heartbreaking reality for many providers. We are our clients’ best advocates (other than themselves, when they are able) and need to challenge insurance and financial barriers in our clients’ best interests. Sometimes, we will appeal denials or even write to the state Attorney General or the state Insurance Commission if the disparity is egregious.

In order to recover, every client needs a support system – recovery is not something you can reasonably do alone, and an eating disorder is very unlikely to go away on its own. Sometimes clients need to be convinced of this as well, but most of the time the families and other support people will do what they can, especially if they get psycho-education about eating disorders. The National Eating Disorder Association, or NEDA is a good resource for education information.

Many people tend to adhere to the stigma associated with mental health care in general and eating disorder stereotypes in particular. Our culture does not make that any easier with an artificial focus on dieting, appearance, and weight that has a long history and is supported through advertisements and social media. Though it is an uphill battle, empowering clients and their support systems to fight stereotypes and ignorance is hugely important. A number of eating disorder associations and advocacy groups have banded together to develop “The Nine Truths about Eating Disorders” that challenge some of the stigma and ideas about eating disorders that make recovery more difficult.

These are a some of the factors that influence care, but none more dominant right now than keeping everyone as safe as possible from the COVID-19 pandemic and still providing the care people need. If a higher level of care is needed, there can be no substitute for in-person treatment. However, many providers are able to provide tele-health now that restrictions have been suspended by many insurers. Providing telehealth can be another ethical consideration, especially in the treatment of eating disorders. Eating disorders are not just mental health disorders, but also medical illnesses. It is important we interact and assess our clients visually, as well as obtain vital signs information like weight and blood pressure, to adequately treat this population. Though in a situation like a pandemic, we might be able to reasonably suspend some of these requirements for a short period of time, in the normal course of events it is not ethical or reasonable to go without that information for long. Telehealth (therapy, nutrition, or medical) would be an appropriate adjunct, but not a substitute for face-to-face interventions.

Though there are other ethical and practical considerations in the treatment of eating disorders, these are some of the highlights we see every day in our practice. Every client, every treatment team is a little bit different. We hope to provide a bridge for clients on their journey in recovery. If you need us, we will be honored to work with you on that journey.

The Importance of Getting it Right: Nutrition Misinformation can be Harmful

 The Importance of Getting it Right: Nutrition Misinformation can be Harmful

By Flavia Herzog Liebel MA, RDN, LDN

Have you ever played whisper down the lane (aka telephone) when you were a child? You may remember one person would whisper a phrase or word into the ear of the person next to them, who would then repeat exactly what they heard to the next person and so on and so on.  At the end, what came out rarely ever matched what the first person said. The end result usually didn’t make sense but was always funny!  ‘Funny’ is certainly the goal in a childhood game, but not so  much when dealing with something as important as nutrition. As a dietitian in private practice who specializes in eating disorders, I have often said that nutrition information is the world’s worst/most dangerous game of whisper down the lane. In my sessions, “Is it true that…” is often followed by a statement or question that varies from slightly inaccurate to potentially harmful. One example that comes to mind is the athlete who told me that they would not eat a banana (which is an excellent source of carbohydrates and potassium) because it was “full of fat” (it is not, there is less then ½ a gram). The other highly worrisome example is when clients tell me they are eating their weight in grams of protein (protein needs are calculated by converting our weight in pounds into kilograms, and then multiplying that by .8 to 1.0; not by eating 1 gram of protein per pound of body weight). In my experience, I have found that most people wholeheartedly believe the misinformation that has worked its way “down-the -lane” to them. Just as in whisper down the lane, the information started off accurate but as it was shared over and over, it had become less and less accurate and ultimately is unrecognizable from where is started.

In my private practice, 90% of my clients struggle with an eating disorder. I am therefore part of many treatment teams that are comprised of amazing therapists, psychiatrists and medical doctors. The treatment team approach has been proven highly effective because all members of the team collaborate and create a united front against the eating disorder. When working as part of an eating disorder treatment team, inaccurate nutrition information that has been “whispered down the lane” to a clinician is not only potentially physically harmful, it can be emotionally harmful to the client as well. When a client receives nutrition information from a therapist/psychiatrist (It is nearly impossible to work with someone with an eating disorder and not, at some point, be discussing nutrition) that is the opposite of what their dietitian is telling them, it breaks down the trust between the client and the eating disorder treatment team. A client’s trust with their treatment team is paramount and when that trust is doubted from a client perspective even for a moment, it gives the eating disorder more power.  This is especially true of the client-dietitian relationship since the dietitian is often viewed as an adversary.  Of equal concern is when there is NO dietitian on the treatment team. There are a number of reasons this may occur (see insert). In these circumstances, it is not uncommon for a therapist or psychiatrist to find themselves discussing any number of nutrition-related topics. No matter the circumstance(s), it is imperative that clinicians share only scientifically valid/evidence-based nutrition information with their clients. They should not be sharing their opinions, nutrition myths or inaccurate information. If you are discussing nutrition with a client, do you know with 100% certainty that what you are providing is evidence -based information?  Or is it possible you are repeating what you’ve heard from someone else, something you believe to be true but may not be able to verify or validate? The best way to ensure that you are providing accurate information is to check your source. Most popular sources you need to be wary of include:

Blogs or Instagram accounts NOT written by an RD or a PhD in nutrition

“Nutritional” websites that are selling you something

Health or Wellness Coaches -that are not RDs or do not have a degree innutrition

Fad Diet books /programs

Personal Trainers – that are not RDs or do not have a degree in nutrition

Note: Athletic Trainers do have significant education, some of it is in nutrition but typically it is only basic nutrition

A nutritionist that is not a Registered Dietitian

Sources you can trust for accurate nutrition information:

Registered Dietitians; to locate one in your area, and with the specialty that you are looking for, go to www.eatright.org  or www.healthprofs.com

Academy of Nutrition and Dietetics www.eatright.org

Dietary Guidelines for Americans www.Health.gov

National Institutes of Health www.NIH.gov

US Department of Health and Human Services www.HHS.gov

URLS that end in .gov, .edu or .org

Reputable websites, to determine if it is reputable check that:

Studies are cited

The article is supported by research published in scientific, peer-reviewed journals

It lists references and studies used to support claims

Learning the truth about nutrition and the human body is a critical piece to eating disorder recovery. When the entire treatment team works together to provide accurate, consistent nutrition facts it is very impactful. Our clients need and deserve to learn the truth from those of us that they trust the most, otherwise their eating disorder can win.