Helping patients recover from eating disorders through PLISSIT
By Andrew Walen, LCSW-C, LICSW, CEDS
Eating disorder treatment centers will tell you they follow the best evidence for care in an effort to convince you to choose their program. But when you ask the staff for details, it’s not clear they really know what best evidence means. I’ve spent a long time treating eating disorders, substance abuse, anxiety, depression, and all the related concerns. What I continually believe works best for me and my clients, and what I have trained my staff in, is to follow a simple acronym – PLISSIT.
This acronym dates back to the founders of cognitive therapy techniques like Albert Ellis and Tim Beck. My mother, Dr. Susan Walen, was the founder of The Baltimore Center for Cognitive Therapy, and was a renown psychologist, author, educator, and protégé of the aforementioned thought leaders. She in turn taught me early in my career the important of using PLISSIT. So, with all this buildup – what in the world is it you ask? Let’s get to it.
P – permission. The first and most important part of the work is giving clients permission to feel the way they feel and let them know they are not some weird alien creature for having an eating disorder. By helping clients normalize their experience given their history, underlying psychiatric concerns, and the society and culture they come from, we are taking some of the anxiety away and developing a therapeutic relationship. Give them the grace of empathy and create that bond. That’s job one!
LI – limited information. The next task is educating our clients about eating disorders, what they are, how they develop and fester, and how they are treated. By taking the mystery out of the disease and what’s needed to recover, we take still more of the anxiety away. If you are going into battle, you are less scared of the adversary if you know more about them. You can predict what is likely to happen and make plans about how to manage those obstacles. But a commonality in eating disorders is obsessive thinking and perfectionism. So, we keep it “limited” to avoid unnecessary overthinking and “what if”-ing. I find it crucial to make sure clients know their specific diagnosis, so they can put a name to the thing they are fighting. It makes it real and tangible. It’s hard to punch a cloud.
SS – specific solutions. The goal here is to give clients the tools they need to recover. We talk about eating disorders being a disease of anxiety (sensing a pattern here yet?). To get past anxiety, you must be exposed to it over and over again. That’s why our clients eat meals with us in the program every day. We teach them how to identify and then cope with their physical, emotional, and behavior response to eating, a treatment modality called exposure and response prevention (ERP). The more this is done, the more clients learn to tolerate their anxiety using the tools they are taught in groups and individual therapy. Those tools are part of a treatment called Dialectical Behavioral Therapy (DBT). The work may include distraction techniques, deep breathing, muscle relaxation techniques, and other skills. From there we work on Cognitive Behavioral Therapy (CBT) skills. Clients learn to identify if their thoughts are rational or irrational and how to dispute those irrational ones. There’s a lot more to it, but this is a snapshot of the work.
And finally …
IT – intensive therapy. This is, in essence, digging in the dirt. Some clients may never get to this stage if they can’t figure out how to tolerate their emotions and challenge their unhelpful thought patterns. For clients who are ready for this, the goal is to unpack the root causes of their disorder, the role of society, family, trauma, neglect, and other issues that may have impacted their physical and emotional wellbeing. It’s hard work and takes the longest amount of time. But for those who can get here, it’s a journey worth the trip.
So, there it is – the whole model. Elegant in its simplicity, and powerful in its efficacy. While most programs do some version of this, it may not be well thought out and planned. For us it is. If we can help you reach the goal of full and sustained recovery from your eating disorder, please reach out.
Results matter. Plain and simple, when you are looking for a treatment program to help you or a loved one recover from an eating disorder, the most important questions should be if the program can really help. Outcomes measures are the best way to truly know.
An outcomes measure is a tool used by a program to assess a client’s illness at the start of treatment and measure their improvement over time. The Body Image Therapy Center began using just such a tool in the last quarter of 2018. We chose the Change in Eating Disorders Symptoms (CHEDS), which is a 35-item self-report designed to track changes in eating disorders symptoms over the course of treatment or time. We use it to measure overall symptoms, but also to look at sub-scales including:
CHEDS scores are used during the course of treatment to see if a client is improving in one area but not in another. For example, a client may have stopped bingeing and purging, but their body pre-occupation and body dissatisfaction may be getting worse. We can then target our interventions to address those areas more directly.
This week we had enough data to run our first analysis on total recovery scores to see if our clients were reaching clinically significant recovery. We looked at adult clients who entered either our Intensive Outpatient Program (IOP) or Partial Hospital Program (PHP), had CHEDS scores that indicated a clinically significant eating disorder, and stayed for a minimum of four weeks (n = 26). We chose four weeks as an inclusion cut-off as our experience is clients require at least that much time to assimilate into the program and begin to do the necessary clinical work toward recovery. Of that number, we found 20 clients met criteria for clinically significant recovery. This suggests The Body Image Therapy Center has an 80% success rate.
There are a number of clients who were not included in this assessment due to very short stays in treatment or failing to start treatment after their initial assessment. As any good researcher will tell you, those number still count when you dig into the medical journals. In fact, rates of recovery for adults range anywhere from 0 to 25% for anorexia, top out at 30% for bulimia, and vary widely from 18 to 86% for binge eating disorder depending on the study (Murray, 2019). Those formal studies include everyone who started treatment. Ours is not a formal study and the results are observational only.
But for the client who comes to The Body Image Therapy Center and wants help, is ready, and has the support of their loved ones, it’s clear we have the outcomes that speak to a successful recovery. As the founder and executive director, I’m incredibly proud of these early results, but especially of my team, and the resiliency of our clients.
Recovery is possible. We have proof.
Stuart B. Murray (2019): Updates in the treatment of eating disorders in 2018: A year in review in eating disorders The Journal of Treatment & Prevention, Eating Disorders, DOI: 10.1080/10640266.2019.1567155
It’s hard to know the right thing to say to your loved one in treatment for an eating disorder. These are some examples of what we often hear from our clients that are unhelpful and some ideas on how to be more supportive.
You didn’t eat much today. Are you even trying?
Eating disorders aren’t about food. Don’t comment on what a person is or isn’t eating as that just brings up feelings of anxiety and may trigger more eating disorder behaviors.
Try “I’m concerned about you,” and try to get them to talk about how they’re feeling. Listen without judgment and offer to help in any way you can.
Have you lost more weight? You look like a cancer patient.
You may think your question shows concern, but it too stirs up anxiety and negative behaviors. Don’t focus on appearance. Ask them about their life and see what’s going on. Show them you care about them without drawing attention to food or body image.
You just need to eat more. Why is that so hard?
It may seem like this is a simple solution, just like “stop over-exercising” or “stop binge eating.” But this is a mental illness. It would be like telling someone with depression to “just look on the bright side!”
It’s your favorite food! Why won’t you just take a bite?
This kind of comment makes someone feel guilty, and probably makes the eating disorder voice louder in the sufferer’s head.
Try: “Can you remember the tips your therapist suggested?”
Don’t you care that you’re hurting yourself? Don’t you see you’re hurting me too?
A better approach than blaming your loved one for their struggles is to offer empathy.
Try: “I really care about you. Is there anything I can do?”
That food is so fattening. Have you considered being vegan or going on a Keto diet?
Those who struggle with binge eating will often use high fat and high sugar foods, which increases their sense of shame about the behavior. Anorexic clients typically consider those food “forbidden” as well. Food is not good or bad, healthy or unhealthy.
Try: avoiding discussions about food, calories, and weight. If you talk about food, it’s okay to say, “That sure was yummy.”
“I wish I could lose weight like you,” or “I wish I was just a little bit anorexic.”
People with eating disorders aren’t making lifestyle choices; they’re struggling with illnesses.
Try: “I support everything you’re doing to recover.”
You must think I’m really overweight!
The eating disorder isn’t about you. It’s about how the sufferer feels unlovable and unworthy themselves. Talk about what makes you proud of people.
Try: “I’m so moved by your piano playing!” or “You made me feel so loved today!”
You don’t look like someone with an eating disorder.
People with eating disorders come in all shapes, sizes, colors, genders or age.
Try: “How can I help you?” or “Can you try to help me understand what thoughts and feelings you’re having?”
You look so much better.
It sounds like a motivating compliment, but for the person with an eating disorder it may trigger negative thoughts about their body like, “You’ve gained weight!”
Try: “It’s great to see you!” or “I missed you so much!”
If you or someone you love needs help navigating the path toward recovery, please contact us at 877-674-2843 or email@example.com.
After twenty years of practicing as a licensed psychotherapist, I have deep respect for the power of self-fulfilling prophecy. According to Cognitive Behavioral Therapy (CBT), our thoughts precede our emotions and our behaviors. If we allow our Inner Critic to put us down with negative and shame inducing thoughts about our bodies and our relationship with food, we spiral down in an endless avalanche of self-sabotage.
We all must:
Choose something different.
Choose something better.
Reprogram your neural pathways by shifting to positive self-talk through the power of affirmation. In a moment of quiet meditation or reflection, say and repeat each of these twenty-five affirmations aloud. Consider choosing one per day and repeating it ten or more times. Make it your mantra for the day and say it anytime you notice your Inner Critic rearing its ugly head with negative thoughts.
“I am grateful to my body for safely and lovingly housing my spirit.”
“I have tremendous gratitude to my body for all the miraculous things it does for me each and every moment.”
“My body is filled with health and vitality.”
“My heart is filled with peace, love and joy.”
“I notice the feeling of aliveness in my body and am reminded that I am made of divine light and love.”
“I am not my weight or my waistline–I am the perfectly unique spirit that lies within.”
“I am my own loving parent, caring for my body as I would somebody I love very much.”
“I thank my body for its strength, flexibility, balance and resilience.”
“I honor by body with loving thoughts and healthy choices.”
“I have compassion for my body, honoring all it has been through and lovingly take responsibility for caring for it from here forward.”
“I forgive myself for at times neglecting my body. I understand this was a normal response to my nature and my nurture.”
“In an effort to free myself, I release any blame or resentment I hold for myself or anybody else, in relation to my feelings about my body.”
“One day at a time, I will remember my body is sacred and behave accordingly.”
“I care for my body by caring for myself and putting myself together as the beautiful person that I am.”
“I practice self-compassion and forgive the behaviors of the past. I understand they were part of my journey and am thankful for the lessons.”
“I choose love over fear and self-hatred.”
“I choose and bless the healthy food that nourishes my body, mind and spirit.”
“I say no to shame and self-sabotage.”
“I understand I am a human being, that we are all works in progress and I am not expected to be perfect.”
“I surround my body with loving light of compassion that protects me wherever I go.”
At first, you may feel some cognitive dissonance or discomfort as your Inner Critic may cause some resistance into allowing these thoughts to resonate with your mind, body and spirit. Keep “talking the talk” until these affirmations become your new belief systems leading the way to a new life filled with self-love and body positivity!
“The first step toward change is awareness. The second step is acceptance.”
Journaling can be a powerful activity to promote insight and self-awareness. If you would like to improve your relationship with food, set aside 30 minutes in quiet solitude to write out your responses to the following prompts. You can do this on paper, a tablet or your computer. There are no right or wrong answers, and this exercise is just for you.
What does “food” mean to you? With what do you associate food and eating?
How would you describe your relationship with food? Is it positive? Negative? Do you go through any noticeable cycles?
Think of the last three times you ate. Describe your emotional state and list what you ate.
Describe the last time you made an unhealthy food choice. How did you feel before, during and after?
Describe the last time you made a healthy food choice. How did you feel before, during and after?
Describe some of your early life experiences with food. How do they connect with how you relate to food today?
Write down what you ate yesterday. Would you feed this to your child, best friend or somebody you love very much? Why or why not?
Name somebody who you believe has a healthy relationship with food. What do you notice about them? How is your relationship with food different? What is between you and having a healthy relationship with food?
Describe what a healthy relationship with food would look like for you and how that would impact the rest of your life (health, work, relationships, etc.)
What do you need to have that healthy relationship with food? What kind of support do you need?
If this exercise triggered any negative feelings, remember we are all works in progress. Practice some self-compassion and self-care and seek support. Consider sharing your journaling responses with a trusted counselor or therapist to support you along the road to recovery and health!
You or a loved one is struggling with an eating disorder. You’re scared about how to get started and what you’ll have to do to get better. Perhaps you’ve even tried to get help, but things aren’t improving. This is how most clients come to us at The Body Image Therapy Center. It’s our job as an eating disorders treatment team to know our stuff, and to be an impartial guide for you on the road to recovery. First step is identifying what kind of care you need, and in what setting that care can best be delivered.
The goal of this blog is to describe why you may be referred to try day treatment as a level of care to help you fight your eating disorder. Day treatment at our program consists of 6 hours a day of care Monday through Friday. It includes 3 meals a day, group therapy, individual therapy, nutrition counseling, and psychiatric services. Let’s look at the various areas of assessment to help understand who is a good fit for day treatment, also known as partial hospital programming (PHP).
Medical status: this is the most important part of the assessment. You need to be medically stable enough so you are not at risk for sudden medical complications. The Academy for Eating Disorders gives concrete guidelines for physical exams, labs, and other tests. As long as your results do not meet inpatient or acute treatment guidelines, you are a candidate for day treatment depending on the rest of the assessment items.
Weight as a percentage of pre-eating disorder weight: A standard guideline for assessing severity of an eating disorder is to determine how much weight you lost after the onset of the eating disorder behaviors. Losing 15% or more of your body weight is a sign that the disorder is significant and needs to be addressed in a day treatment setting at minimum. Weight loss or gain are symptoms of an eating disorder but are not the only factors to consider. There may be medical and natural/biological functions at work. To determine if you are suffering from an eating disorder, it requires investigating how weight and shape play into your mood and behaviors.
Structure needed for weight restoration or stabilization: if you are in outpatient treatment or trying to recover on your own, you may simply need more help. The goal of day treatment is to provide several opportunities a day to practice the act or normal eating and manage the thoughts, emotions, and behaviors that come up at mealtime. Doing this every day, multiple times a day, is how you’ll get past the roadblocks that keep you sick. In day treatment, you can process your thoughts and feelings, and develop the skills to tolerate the distress that comes from following your meal plan and getting better.
Structure needed to refrain from compulsive exercise: the drive to exercise, burn calories, or work compulsively on muscle definition is powerful in those with eating disorders. If you find you’re unable to stop acting on that compulsion, day treatment can give you the support and structure you need.
Frequency of binge eating and/or purging: a good gauge for severity of an eating disorder is the average number of times a day or week you engage in the behaviors. If you’re binge eating, bingeing and purging, or some combination four or more times a week you should be in day treatment to make use of the structure and skills development provided to stop engaging the eating disorder.
Suicidality: if you’re having mild thoughts of suicide but don’t have any intention or ability to act on them, day treatment is still an option for you. One of the biggest risks in any mental health program is when a client has thoughts, intentions, and resources to hurt themselves. That person needs to be stabilized in a residential or hospital program.
Motivation: this is really important. If you’re motivated to recover, even just a little, then you can make use of that motivation and get started in a day treatment program. We expect there to be hard times, lapses in behavior, and fluctuations in your available energy to use your recovery skills. Learning how to recover while living in your home environment has actually been shows to improve outcomes. But it all starts with actually wanting to get better.
Co-occurring disorders: if you have symptoms of untreated or under-treated depression, anxiety, or some other mental health or substance abuse concern, day treatment is the place to start. Having the security of daily monitoring of your symptoms is crucial when you’re going through psychotherapy treatment and psycho-pharmacology treatment.
Environment/social supports: We often see college students and adults who are new to the area as examples of those who greatly benefit from day treatment. If you’re lacking in local supports, or have supports that just aren’t helping, day treatment is also a good fit.
Previous level of care: if this is not your first step in eating disorders treatment, you’re like many of our clients stepping down from inpatient or residential care or up from outpatient or intensive outpatient program (IOP). But if you’ve never had treatment before, day treatment is still an option based on all the other factors we’ve gone over.
It takes a comprehensive treatment team educated in eating disorders and their physical, emotional, and social elements to determine the right level of care. It also takes a level of trust in that team for a client to put themselves and their recovery first and get the care they need. How can we help?
I saw an old friend post on Instagram that he is working to lose a significant amount of weight despite being a healthy and typical-sized male in his 40s. A distant family member posted she is going on a New Year’s cleanse to rid herself of all the toxins from the holidays with hopes of “#cleaneating from now on.” It’s the resolution time of the year. It’s also the most shame- and guilt-filled time of the year. Want to know why?
Resolutions are typically unrealistic and unsustainable. They involve the diet- and exercise-mentality that drives so many to purchase new gym memberships and try recipes typically preferred by rabbits and cows more than humans. The gym routines may last a few weeks, but motivation and time dwindle. Recipes for vegan or ketogenic diets may be the fad among friends and family today but give way to cravings for pizza and beer binges soon enough. The result invariably is guilt and shame, followed by regret, repentance, and repetition of the cycle again.
Instead of resolutions, I ask you to consider joining a revolution focused on your actual wellbeing. There is nothing wrong with your weight. There is nothing wrong with your shape. If you want to work on increasing your energy – cool! You want to work on your emotional health – great! There are all kinds of goals related to physical and mental health that have real, meaningful, validated, and provable benefits. Want to know one that has no provable benefit? Weight loss.
Weight loss won’t make you happier. It won’t make you healthier. It won’t make you more lovable, intelligent, beneficial, or superior. Weight loss as a goal in and of itself has no provable benefits! It may be a modest by-product of lifestyle changes, true. But pushing your body to a weight you pre-determine as “ideal” or “healthy” usually means fighting your body’s own natural set point. The result is physical and emotional harm to yourself. It’s also the pre-cursor to most all eating disorders.
So instead of choosing to lose weight or push yourself to eat perfectly and exercise religiously, consider living in the body you have and not the one you wished you had. That’s a revolutionary idea whose time has come. If you want help learning how to do that, give us a call.
As each client is unique, the length of treatment in our day treatment program varies anywhere from two weeks to twelve weeks, or more. Our goal to have you successfully complete the program in the minimal time possible, without subjecting you to being prone to relapse by stepping down to a lower level of outpatient care before you are ready.
Will I have to miss work?
Because our programs run from early morning to late afternoon and can be emotionally demanding, it is unlikely you would be able to complete the program without taking time off work. If you don’t want to tap into vacation time or don’t have it, it’s important to remember that through the Family and Medical Leave Act, you may be able to take unpaid time off of work for medical treatment. You do not have to disclose the nature of the health concerns as that is your private information.
Would I have to stay overnight?
No! The beauty of our day treatment or Partial Hospitalization Program (PHP) is that you can receive incredible support during the daytime, but are able to stay in the comfort of your own home or accommodations of your choice during nighttime.
What is the cost? Do you take insurance?
We are an in-network provider with most major insurance companies. We also accept all other insurances that have out-of-network benefits. Our intake department would be happy to verify your insurance benefits prior to your treatment and let you know your out-of-pocket costs before your treatment. To reach our intake staff please call (877)-674-2843.
How many other patients will be there? Will they be similar to me?
We typically have about 8-12 patients over age 16 participating in our day treatment or PHP at any given time. Our clients each have their own unique situations, but most are dealing with an eating disorder such as anorexia, bulimia, binge eating, compulsive exercise, and other related conditions. They also are commonly struggling with depression, anxiety, trauma, or self-esteem challenges. We treat all genders with respect, dignity, and cultural awareness of their needs.
What is the food like? What if I don’t feel comfortable eating with other people?
We have on-site meals prepared by Johnson and Wales-trained chefs in our beautifully designed kitchens. Yes, it is common for people dealing with eating disorders to experience anxiety and difficulty eating in front of others. Learning how to cope with that anxiety in the safety of the program with support from staff and peers vital to beating an eating disorder. This is why eating two snacks and lunch together is required as part of the program, and we are there to support you every step of the way! We have a large focus on nutrition recovery.
What is a typical day like?
You will likely participate in individual and group therapy and nutrition counseling. Meeting with our medical doctors and psychiatrists (who may prescribe medications for any issues such as depression or anxiety) occur once per week.
What is the criteria for me to participate in Day Treatment?
Regarding eating disorder issues, you would be a great candidate for day treatment if you need more support and structure to gain/stabilize your weight, meet your nutritional needs, or refrain from behaviors such as compulsive exercise, bingeing or purging.
If you are also dealing with mental health issues, you are a good candidate for day treatment if your symptoms are interfering with school, work or other aspects of life. If you have mild suicidal thoughts without a plan or intent, you are a good fit for this program.
As far as your medical status, day treatment requires that you be medically stable to the point where you do not require daily medical monitoring. Your weight as a percentage of your pre-eating disorder weight must be greater than 80%.
Who do I contact for more information? How do I get started?
Please contact us to schedule an initial evaluation to determine if Day Treatment or another level of care is best for you. Please give us a call at 877-674-2843 or contact us at firstname.lastname@example.org.
When clients come in for treatment for their eating disorder, everyone involved – from the client and loved ones to their treatment team – are in crisis mode. We’re all busy figuring out what are the symptoms, what are the stressors, triggering events, underlying mental and physical health diagnoses, and how to help alleviate the client’s immediate suffering.
For those of us in the treatment field working with insurance companies and oversight organizations that review the quality of care provided, we hear over and over that we must think about discharge planning from the moment the client comes into treatment. It’s hard to do, seems counterintuitive, and even onerous at times. We just want to dig into the work of helping the client recover, and honestly its all the client typically is thinking about too.
In reality, the preparation for ending care is every bit as important as the work done in active treatment. Therapy ideally is not something we engage in forever. We should be teaching the tools of recovery, so the client becomes their own therapist for the rest of their lives. The best therapists are the ones who don’t allow their clients to become treatment dependent. So, while it may not seem like a task we want to engage in, we have to start working on relapse prevention and discharge planning from the start.
Let’s talk about relapse prevention and what that means. Originally used in the field of addiction treatment but now universally accepted for all mental health concerns such as eating disorders, there is a concept of the Stages of Change. The stages represent how we see a client engage offers of help to recover. They are:
Precontemplation – the client has no awareness or belief that they are struggling
Contemplation – they client has some awareness of a problem and is considering seeking help
Preparation – getting a list of resources to get help and preparing physically and emotionally to get that help
Action – in the process of treatment and recovery
Maintenance – the client is in a state of recovery and doing well
Relapse prevention – the client is ensuring their recovery by actively using their recovery tools and being mindful of possible pitfalls that could lead to a lapse in old behaviors or full relapse
The last stage is something a lot of people miss out on altogether and is why so many return to old negative behaviors to cope with life’s downturns. That sense of invincibility creeps in during the maintenance phase, and many don’t do the work necessary to plan for the unexpected.
The following is a quick look at what you can do now to start preparing for that wonderful day when you no longer need treatment but still need to remain mindful of relapse prevention.
Eating disorders begin with negative thoughts about yourself, your body, the world around you, and your future. First step in prevention is to be aware of your thinking. Keep a regular journal and review your writing periodically. Notice patterns of negative thoughts that may be creeping back in and start to dispute them with your rational, healthy, and coping skill thoughts.
Pay attention to possible triggers that could lead to relapse such as people, places, and things. Are you surrounding yourself with folks fixated on diet talk? Are you in a gym that is promoting weight loss at the holidays? Does your office have a bunch of fashion magazines lying around that promote the thin-ideal and fat shame others? What changes can you make here?
Develop a group of like-minded recovery-oriented relationships both in-person and online if necessary. If you find yourself slipping into old patterns of compulsive exercise, comparison thinking, compulsive thinking about the quality of food, or other eating disorder patterns, practice asking for help from them.
While people, places and things may be external triggers you are familiar with, are there internal triggers you can identify as well? Examples include: emotional states, feeling physical pain or illness, loneliness, isolation, unmet hunger cues? If you recognize these, what are the coping tools you learned in treatment? Go back to the basics!
Relapse prevention techniques are varied and plentiful. Working with your therapist from the start to identify what really worked to help you in the act of treatment must become a tool in your toolbox to return to time and again during the course of your life. Whether it’s a way to identify irrational thoughts and dispute them, practice acceptance skills, self-soothing strategies, or behavioral interventions, have them at your fingertips. While you may dip in and out of a lapse into a behavior for a moment, using your learned skills can help you avoid a full relapse into your eating disorder.
And while we certainly hope you don’t need to return to therapy, know that we’re always there if you need us.
The Body Image Therapy Center is located in Baltimore and Columbia, Maryland, Washington, D.C., and Alexandria, Virginia. If you or a loved one needs help with an eating disorder, you can reach us at email@example.com or by calling our intake line at 877-674-2843.