Walden Behavioral Care - Eating Disorders Treatment and Recovery Blog
The Walden Eating Disorders Treatment and Recovery blog offers stories from experienced clinicians, individuals in recovery, family members in support and also offers effective treatment for eating disorders including anorexia, bulimia and binge eating in a range of settings, including inpatient, residential.
Negative body image is often one of the first symptoms of an eating disorder to appear, yet one of the last symptoms to resolve. While you are recovering from your eating disorder, you will likely experience negative thoughts and feelings towards your body. Luckily, there are some ways to work on improving body image. In the beginning stages of treatment, I often help clients to work toward shifting from body rejection to some form of body acceptance. Eventually – as is appropriate and realistic – we can work toward becoming more positive and affirming.
So how do we start shifting negative thoughts around body weight and shape?
1. Be open about how you are feeling! If you feel uncomfortable, talk to your therapist and fellow group members about it! Even if they can’t “solve the problem” in the moment, they can definitely share in carrying the burden! This work is hard and it is common to experience discomfort in working through these difficult emotions!
2. Know that cognitive distortions are real symptoms of eating disorders. Remind yourself of this when you look in the mirror. There are a lot of really helpful interventions that you and your treatment team can practice to combat thoughts like, “My arm just got bigger from eating that sandwich,” or “I will gain 10 pounds if I eat this cookie.” Your therapist can help you sort out more about how these distortions impact how you feel about your body.
3. Wear clothes that you feel comfortable in! This might mean buying new clothes for the body that you have TODAY. Nothing feels worse than cramming yourself into pants that are too small or hiding in baggy pajamas.
4. Donate or dispose of clothes that you associate with your eating disorder. Have a pair of pants you feel you must fit in to? Or, do you have clothes that only fit when you are manipulating your food intake in an unhealthy way? Well, say goodbye to those pieces – some people even do special goodbye ceremonies with their therapist around these items!
5. Get RID of that pesky scale. In recovery, it is often a goal to work toward connecting more to our internal bodily queues. As we start listening and responding to the signs our body innately gives us when we are hungry, it is natural to experience weight changes. Having a scale can sometimes be a distraction from your long-term recovery goals. While knowing your weight can be a great exposure therapy tool (to minimize power that the number has on worth and affect), I would strongly advise that this intervention be utilized WITH your treatment team as is clinically indicated and appropriate.
Body image is complicated for everyone – especially those who have a history of an eating disorder. Be patient and have compassion for yourself. Body acceptance and neutrality are difficult concepts that take time and require a lot of hard work. Just know that you can do this, and it will be SO worth it.
If you think you might need some extra support, we can help you.
Nina Gilbert, LMSW is an Adult Clinician at Walden Behavioral Care in Guilford, CT. Nina leads weekly body image groups that focus on helping patients connect with underlying emotions and insecurities that become manifested in obsession with the body. Nina earned her Master’s Degree in Social Work from Fordham University in 2012 and an undergraduate degree in psychology from Goucher College, 2006.
Henry James had it right all those years ago, “Three things in human life are important: the first is to be kind; the second is to be kind; and the third is to be kind.”
Here we are, one week after two suicides by people who lived in the spotlight and from the outside, they seemed to ‘have it all.’ But what is having it all? Does anyone have it all? The answer is no. We all have our ‘stuff.’ Some people are better able at hiding their sadness than others. Unfortunately, unlike a broken arm, sadness can be hard to see at first glance.
We all have days that just don’t feel right, days where we want to crawl back in bed, wishing we could either begin the day again or that the day would just go away. It is in these times that we need one simple thing, kindness. Kindness to ourselves and to each other and we need to acknowledge that these days exist for everyone.
Kindness comes in all shapes and forms. It can be a small glance of understanding that lets someone know they aren’t alone or simply letting them know that your door is always open if they ever need to chat. Perhaps one of my favorite examples of kindness is an exchange between the great Winnie the Pooh and his friend Piglet.
“Piglet?” said Pooh.
“Yes Pooh?” said Piglet.
“Do you ever have days when everything feels… Not Very Okay At All? And sometimes you don’t even know why you feel Not Very Okay At All, you just know that you do.”
Piglet nodded his head sagely. “Oh yes,” said Piglet. “I definitely have those days.”
“Really?” said Pooh in surprise. “I would never have thought that. You always seem so happy and like you have got everything in life all sorted out.”
“Ah,” said Piglet. “Well here’s the thing. There are two things that you need to know, Pooh. The first thing is that even those pigs, and bears, and people, who seem to have got everything in life all sorted out… they probably haven’t. Actually, everyone has days when they feel Not Very Okay At All. Some people are just better at hiding it than others.
“And the second thing you need to know… is that it’s okay to feel Not Very Okay At All. It can be quite normal, in fact. And all you need to do, on those days when you feel Not Very Okay At All, is come and find me, and tell me. Don’t ever feel like you have to hide the fact you’re feeling Not Very Okay At All. Always come and tell me. Because I will always be there.”
My wish for each of us is to keep kindness at the tops of our minds and to try to bring a new level of kindness to today. Taking that extra minute to make someone’s day just a bit brighter doesn’t take much and a little can go a long way.
So go ahead and put kindness into action. Take the time to stop and look more deeply into someone’s eyes and see how they are doing, because they may not be as ok as they appear. Simply offering a friendly smile to someone you know – or even someone you don’t – could make a world of difference in helping them feel that they are not alone and in making their day a little less, Not Very Ok At All.
We all do it – we turn to Dr. Google and type in the name of an illness or symptoms we are experiencing because we are concerned for ourselves or someone we love. We quickly scan the results that load and either feel relief, “phew this is not what I have”) or concern “wow, this all sounds like me.” So what is Anorexia Nervosa?
According to the The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the following are diagnostic criteria for Anorexia Nervosa:
• Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory and physical health
• Intense fear of gaining weight or becoming fat, even if at a significantly low weight
• Disturbance about body weight or shape, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of current low body weight
Anorexia Nervosa is one of the most complicated mental health disorders with serious physical and emotional consequences. It’s important to recognize that although sudden and dramatic weight loss is often what most people think of when they hear the term (and what typically makes it to headlines in media outlets), there are many behavioral and emotional symptoms that people experience.
Below are 10 signs that might indicate that someone has anorexia nervosa. Keep in mind that a person does not need to exhibit all of the symptoms below to be in need of support:
• Preoccupation or obsession with weight, food, calories and dieting
• Fear of gaining weight
• Excessive exercise
• High anxiety about gaining weight
• Social withdrawal
• Denial of low body weight, harmful behavior or the severity of the condition
• Thoughts of suicide
• Abnormal or ritualistic eating habits, such as eating foods in a certain order, excessive chewing and rearranging food on a plate
• Covering up in layers of clothing to conceal their body
If you are living with a mental illness, and let’s remember that’s 1 in 5 of us in any given year, it can be hard to accept what you are experiencing and ask for help. If you are supporting a friend or family member in the throes of mental illness you need to know what you should be looking for and what resources are available and necessary.
Denial plays a major role in all eating disorders. If you are worried that you or someone you know has anorexia nervosa, learn more, consider taking an online quiz and talk to a professional.
Kristin Brawn is the assistant vice president of marketing and community relations at Walden Behavioral Care. She is responsible for developing and executing proactive community relations strategies that raise awareness of the programs and services that Walden offers. To achieve this, Ms. Brawn works closely with Walden staff including executives, program directors and marketing and community relations associates to promote programs, events and new initiatives. She also maintains close relationships with crisis centers, mental health providers, dietitians and doctors in New England and leverages regional and national partnerships with key eating disorder organizations. Prior to joining Walden, Ms. Brawn spent a decade working for the nonprofit Multi-service Eating Disorders Association (MEDA) in Newton, Mass. She began her career at MEDA as an office coordinator, but was quickly promoted to roles of increasing responsibility including director of project management, chief operating officer and executive director. As executive director, she worked closely with the board of directors to manage finances and raise funds to help elevate the organization. She was also responsible for coordinating MEDA’s national conference which included selecting speakers, overseeing conference advertising and marketing and coordinating volunteers. Ms. Brawn earned her bachelor’s from the College of the Holy Cross and her master’s from Boston University School of Public Health.
There is no shortage of research demonstrating a higher prevalence of eating disorders among the lesbian, gay, bisexual, transgender, queer and questioning (LGBTQ) community. A 2015 study published in the Journal of Adolescent Health, for instance, revealed that an eating disorder diagnosis is highest among individuals who identify as transgender, and higher still among people who identify as a sexual minority (i.e., lesbian, gay, bisexual) when compared with heterosexual women who identify as women (i.e., cisgender females). The Journal of Social and Clinical Psychology revealed gay and bisexual men exhibit symptoms of eating disorders at a rate of ten times more than heterosexual men.
Despite this, there’s little evidence-based research on effective treatment practices for this population, sometimes making it difficult for healthcare providers to meet the distinct needs of the LGBTQ community. Additionally, many providers lack adequate knowledge of the unique issues faced by LGBTQ people, such as life stressors due to marginalization, the ways in which bodies and identities intersect and the importance of establishing outpatient providers that are welcoming and educated about their specific needs.
Inclusive treatment environments – built on knowledge, respect, empathy and understanding for everyone – are imperative. Based on my work as an eating disorder specialist, and my own experience as a member of the LGBTQ community, I’d like to share a few tips:
1.) Develop cultural humility. This is defined as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the person.” Cultural humility should be viewed as an evolving concept, not a predefined end product. This requires gaining an understanding through self-education so as not to tokenize a person or group of people. We can act equitably by reading books, blogs and pausing in conversation to make room for other, perhaps-less often-heard, voices.
2.) Include names and pronouns during introductions. This not only applies to clients, but for ourselves and our colleagues. By introducing ourselves using names and pronouns and asking the name and preferred pronouns of those we meet, regardless of whether they choose to answer, we side step treating people differently based on our own assumptions and biases.
3.) Properly identify gender neutral spaces. Although gender-neutral bathrooms are becoming more common in workplaces, college campuses and other public areas across America, more can be done. Explicit signage – such as gender-neutral bathroom signage, rainbow decals or transgender flags – is highly encouraged. They communicate a welcoming and safe space for all types of individuals. Signage that is not backed up through staff training can be more harmful as the person may have let their guard down and feel more vulnerable to offenses.
4.) Host a training. Knowledge is powerful in creating inclusive settings. There are many great organizations offering workplace trainings, some free of charge. This includes a local chapter of Gay, Lesbian, and Straight Education Network (GLSEN), Massachusetts Trans Political Coalition (MTPC), Hispanic Black Gay Coalition (HBGC) and/or your local college’s LGBTQ Center.
Change is a process, and signage, training and self-education is a good place to start – though not the ending point. A more complete list of best practices on working with LGBTQ populations, as recommended by the APA (American Psychological Association), can be found here.
For members of the LGBTQ community seeking help for eating disorders, Walden offers key resources and a dedicated treatment track.
If you’re anything like me, you may have a plethora of questions about things you’ve read, thought or heard. Feel free to email me and we can make sense of it all together. CLANG@Waldenbehavioralcare.com.
Christine Lang, MSW, M.Div., is an adolescent clinician in the partial hospitalization and intensive outpatient programs in Amherst, providing individual, family and group counseling for adolescents and families with eating disorders. She received her bachelor’s degree in Psychology and English from Clark University, a master’s of divinity from Pacific School of Religion, and a master’s degree in Clinical Social Work from Simmons College. Christine is particularly interested in working at the intersection of trauma and addiction, and how that connects to identities of gender, sexuality and religion/spirituality. She utilizes Motivational Interviewing, Cognitive Behavioral Therapy, and Dialectical Behavior Therapy in her relational, strengths based and trauma-informed approach. In her spare time she enjoys reading and writing poetry, taking pictures outside and spending time with friends and family.
When it comes to risk factors for the development of binge eating disorder (BED), there’s always an interaction between nature and nurture; in other words, there is no one thing that “causes” BED. Research has shown however, that there are a few biological and environmental factors that could indicate a higher risk of developing binge eating disorder.
Biology: Your family background can put you at increased risk for binge eating. We know from genetic research that people with parents who binge and emotionally eat are at greater risk to develop the same behaviors. Current findings suggest that the role of genes may be stronger for women than men.
Childhood Maltreatment: There is evidence to suggest that experiences of childhood neglect or abuse may increase risk for the development of binge eating. There is also data suggesting that many men and women with BED report a history of other types of trauma. People who survive traumatic experiences develop many ways to cope with those experiences and binge eating can be one of those ways.
Body Image: This one plays a role for most people with BED. The pursuit of unrealistic societal body ideals places people at higher risk for binge eating behavior. Adolescence tends to be a common time period for these thoughts and judgments about one’s body to begin. For many people – of all genders – the difficulty meeting such impossible standards leads to body dissatisfaction. Many people report early experiences of commentary on their body or weight from family, teachers, coaches or peers. Certainly these experiences increase a person’s attention to shape and weight and can increase the likelihood of bodily discontent.
Dieting: One consistent finding in adults and adolescents experiencing binge eating, is a history of attempts to diet. When people make efforts to eat less, go long periods of time without eating or cutting specific foods out of their diet, they are actually at increased risk of binge eating (aka loss of control eating). We know that people who attempt to alter their diet in significant ways will actually focus on and think about food more often than they did before they tried to change their diet.
Emotions: People who tend to act impulsively in response to strong emotional states, are at higher risk for developing binge eating. We know that binge eating often has the short term effect of lessening or relieving distressing emotions. Many people who turn to this behavior, do so because it works – in the moment. What many come to realize is that the behavior doesn’t serve them well in the long term. Recognizing the emotions that often lead to binge eating – and learning alternative behaviors to manage these emotions in a more adaptive way – are a core aspect of the treatment for BED. Knowing about these risk factors can help you understand your eating disorder, but the best place to focus is on the things you can control. What is within your control are your behaviors – even if it doesn’t feel like it during binge eating episodes. There are treatments available to help you disrupt these patterns of behavior and start changing the way you manage uncomfortable emotions.
If you are interested in learning more about the treatment options available at Walden Behavioral Care, please call 888 -791-0004 to schedule an initial evaluation. There is no commitment to treatment – I always tell clients to consider it an opportunity to meet our staff, see our space and learn about what we offer to help you stop binge eating.
Dr. Kate Craigen is the clinical director of binge eating and bariatric support services. She is responsible for the clinical development and consistent implementation of binge eating disorder programming across Walden’s inpatient, residential, partial hospitalization, intensive outpatient and outpatient levels. Additionally, Dr. Craigen collaborates with various bariatric providers and partners throughout New England, ensuring both pre- and post-bariatric surgery patients gain the proper behavioral skills to enhance long-term outcomes. Previously, she was a clinician in Walden’s partial hospitalization and intensive outpatient programs in Waltham. She also served as a postdoctoral fellow and clinical instructor at the Eating and Weight Disorders Program in the Department of Psychiatry at the Mount Sinai School of Medicine. Dr. Craigen received her doctorate in clinical psychology from Fairleigh Dickinson University. Her professional interests include the role of supervision and training in the field of eating disorders and the role of gender in the diagnosis and treatment of eating disorders.
Early Sport Specialization (EES) is a relatively new topic that is gaining momentum due to the high demands and negative consequences that are impacting the psychological and medical statuses of today’s youth. Early Sports Specialization is defined as intense, year-round training – in a single sport with the exclusion of other sports – starting as early as middle childhood. The world of youth sports is quickly changing and children are committing themselves earlier and earlier to one particular sport in the hopes of achieving elite level success. While being passionate about an extra-curricular activity that can have so many benefits is wonderful, it also has the ability to cause debilitating conditions like eating disorders that are detrimental to healthy development.
Here are some important things for parents, caretakers and coaches to keep in mind for their children and students who take an early interest in one sport.
Puberty can affect an adolescent’s relationship to their body and their sport. While healthy adolescent growth means experiencing changes to weight and shape, many teens have a difficult time adjusting to these developments – especially athletes who have specialized in a sport at an early age. For athletes, these changes not only affect feelings around their bodies, but can also be seen as negative implications to their athletic performances. What we know about athletes, is that they often adopt the “whatever it takes” mindset which makes them more likely to engage in practices (such as dieting or over-exercising) that will increase their sport performances.
Eating disorders can be harder to detect in the athlete population. Many athletes – and their families and coaches – are unware of disordered eating practices due to a concept that is called sport specific deviance. Sport specific deviance is the idea that certain thoughts and behaviors are considered “deviant” by an individual outside of a specialized community, when within the context of those involved in the specialized community, the same behaviors or thoughts are normalized. For this reason, many individuals belonging to sport community may be unaware that they are engaging in disordered eating patterns as it not considered an abnormal practice within their sport culture. This deviance in sport can often lead to late detection, which we know decreases one’s chances at lasting recovery. Living with an eating disorder for an extended period of time can cause such extreme physical and psychological complications that returning to sport could be detrimental to an athlete’s health.
Focus on one activity can lead to burn out – and psychological distress. Burnout is another consequence that goes hand and hand with early specialization. Burnout often occurs when athletes start specialization early and miss out on things outside the realm of sport like extra – curricular activities and peer interaction (activities that are vital to healthy adolescent development). When athletes experience this burnout, it can often leave them feeling as though they have lost part of their identity when their sport does not bring them the same joy. For these young athletes, losing such a huge part of their identity can have detrimental effects on self-esteem, self – worth and overall psychological functioning. This is when we often see the development of eating disorders as a way to fill this void.
Early Sport Specialization can cause physical injury – and impact psychological status. In adolescence, early sport specialization is the cause of many overuse injuries. It can be hard enough to properly fuel an adult body engaging in such vigorous physical activity, but when you add the element of a growing adolescent body, and a still developing brain, malnutrition is a very common occurrence. Compounding all of those considerations with the very real possibility that disordered eating is likely being practiced, the implications can be devastating. Did you know that about 50% of all injuries seen in pediatric sport medicine are related to overuse? Due to the high demand of these sports and young athletes’ growing bodies, many experience bone fractures, sprains, dehydration and may even be encouraged by their pediatricians to discontinue physical activity altogether. As a result of missing practice and/or competition, young athletes often engage in extreme dieting or other eating disorder behaviors in order to keep their competitive edge during times of inactivity.
Although it is clear that early sport specialization has the ability to fuel eating disorders, it does not mean that every young athlete will develop an eating disorder. Early detection and intervention is key when working with young athletes. Starting the conversation about the importance of a well – balance, flexible diet and lifestyle is extremely important. Here at Walden Behavioral Care, we understand that this is an underserved and undereducated field with regard to eating disorders and so we are making it a priority to visit trainers, coaches and sports teams in order to spread awareness of the unique eating disorder presentations experienced within this population.
If you are interested in learning more about our work with athletes, I would encourage you to visit our GOALS website!
Baker, J., Cobley, S., & Thomas, J. (2009) What do we know about early sport specialization?, High Ability Studies, 20 (1) 77-90
Brenner, J. (2007) Overuse injuries, overtraining and burnout in child and adolescent athletes, The American Academy of Pediatrics, 119 (6) 1242-1245
Malina, R., (2010) Early sport specialization: roots, effectiveness, risks, Curr Sport Med Rep. 9(6), 364-371
Thomas, J., Cote, J. & Deakin, J. (2008) Examining adolescent sport dropout and prolonged engagement from a developmental perspective, Journal of Applied Sport Psychology 20(1), 318-333
Torstveit, M. K., Rosenvinge, J. H., & Sundgot‐Borgen, J. (2008). Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study. Scandinavian journal of medicine & science in sports, 18(1), 108-118.
You may be wondering, what exactly is expressive therapy? At its core, expressive therapy is the use of some kind of creative art form– which can include drawing, painting, writing and even movement like dancing and acting – in order to assist in the processing and communication of difficult emotions. The basic premise is that in using our imaginations, we can change or accelerate the healing process – especially for those who are having a hard time with or who have stalled in traditional talk therapy work.
Expressing feelings and emotions verbally can be extremely difficult for anyone – especially adolescents living with an eating disorder. Being an adolescent is hard. Emotions and impulses are amplified. The frontal lobe hasn’t completely developed which can make logical decision-making and processing a difficult feat. Pair all of these things with an eating disorder, and you can begin to understand the struggle that many adolescents work through on a daily basis. One of the many reasons I love this intervention, is that it gives adolescents an opportunity to take the “pressure” off themselves and onto the paper, in a way that can feel less intrusive than an individual talk therapy session. There is also a lot more opportunity for more abstract thinking which can facilitate greater insight from both the client and the therapist working with them.
Group expressive therapy can promote the building of meaningful relationships. What we know about eating disorders is that they thrive in secrecy and isolation. One of the biggest goals for anyone that comes to us for treatment is the creation of or reconnection to friends and family. Expressive therapy is a great way to engage other members in program in a way that helps facilitate mutual understanding and empathy. As an individual shares their work, other group members can comment on what they are seeing in order to validate shared experiences and/or build insight into what is going on for themselves.
Expressive therapy can help increase and foster self-esteem. For many teens – especially teens living with eating disorders – self-worth and self-acceptance are often extremely low. Creating art and being able to see a project through start to finish can foster a great sense of accomplishment. Do you remember being little and proudly saying, “Hey, look at what I drew!” Unfortunately, most people stop drawing or practicing art when they are teens, due to feeling insufficient at the task. However, my favorite thing to say to my clients is, “Creating art is not about the finished product – it is about the process.” This is very similar to the idea that treatment is a process. Everybody’s journey is unique and different and one way is not better than another.
In almost all levels of care here at Walden, we make time within the programming day for the adolescents to create artwork. My advice to parents of adolescents living with an eating disorder – or parents of any adolescent – is to encourage them to use art as a coping skill. Having an outlet such as expressive arts is essential to those in treatment, no matter what level of care.
Ashley Cocchi MS, is an adolescent clinician at Walden’s Amherst’s location offering PHP and IOP level of care. She earned her BFA at The Art Institute at Lesley University. She then received her Masters at The College of New Rochelle in New York, studying Art Therapy and Counseling. She is passionate about art and creative modalities and tries to add art in therapy wherever she can. She also loves music, going on adventures, drinking coffee and stand up comedy.
Did you know that women with diabetes have an increased risk of developing an eating disorder? Or that adolescence and young adulthood are particularly vulnerable times for the intentional omission of insulin as a way to manipulate shape and/or weight?
While the intentional omission of insulin is sometimes referred to as “diabulimia,” this isn’t an official diagnosis in the DSM-5 nor is it the recommended term to describe the behavior. The acronym ED-DMT1 is often used for purposes of diagnosing and billing and the DSM-5 phrase “misuse of other medications” as a compensatory mechanism in its bulimia nervosa criteria would include insulin.
The thoughtful, skillful management of these co-occurring conditions can truly be transformative. The stakes are high. The risk of complications and even death are real.
When working with clients or patients who have both type 1 diabetes and eating disorder behaviors, there are a couple of clinical strategies to keep in mind:
1) There is a minimum threshold for safety. Clients need to be able to agree to and take a minimum amount of insulin (for example, an appropriate basal insulin dose). Struggling to do this (as evidenced by consistently, dangerously elevated blood glucose levels or frequent episodes of diabetic ketoacidosis, or DKA) can point to the need for a higher level of care. As with all eating disorders, hospitalization or an inpatient admission can be a life-saving intervention.
2) Medical emergencies can emerge and responding to them appropriately and efficiently is of utmost importance. Both hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose) can be life threatening, and prompt intervention is essential.
Respond to low blood glucose (below 70 mg/dL) quickly – do not wait for the next snack time or eating opportunity. This can be a medical emergency and needs to be treated outside of the meal plan.
Use simple carbohydrates (at least 15 grams) to bring blood glucose into normal range.
Avoid using carbohydrate-containing foods that also have significant amounts of fat or protein.
Glucose tabs or gels can be helpful, especially if treating low blood glucose with food choices increases a client’s vulnerability to binge behaviors.
Relative hypoglycemia – the experience of symptoms of hypoglycemia even when blood glucose isn’t low – can occur following periods of hyperglycemia. These should be treated with 15 g of carbohydrate, too.
Insulin is needed to bring blood glucose levels down.
Glucose toxicity can reduce insulin sensitivity, meaning more insulin is needed to correct higher blood glucose levels.
Correcting dehydration is usually also a component of treating hyperglycemic excursions (and can help patients feel better).
Medical hospitalization may be warranted if signs of DKA are present.
For both hypoglycemia and hyperglycemia, check blood glucose levels again after 15 minutes and continue to monitor the client’s response to the intervention to be sure it was appropriate and adequate.
3) It is essential that the eating disorder treatment team and diabetes team are in close communication. Not only will clients feel well supported when their team is working together, but treatment recommendations and transitions can be made more seamlessly. This can improve outcomes and reduce anxieties for the client. Trust and therapeutic fit matter, so communicate with the diabetes team to make sure recommendations aren’t conflicting and the client isn’t the one left to synthesize the disparate advice.
4) Interrupting the eating disorder behaviors can be uncomfortable. For those with insulin omission as a purging mechanism, reducing or eliminating this behavior can lead to insulin edema, fluid retention that occurs as a result of dehydration due to consistently elevated glucose levels and the now-improving glucose levels. This is physically uncomfortable for clients and can lead to increases in weight (sometimes increases of several pounds or more). Treatment teams shouldn’t react to these shifts as increases in actual body weight. If possible, clients should be educated ahead of time that some edema or bloating is anticipated in order to manage expectations and help tolerate the discomfort that can occur. Fear of weight gain and feeling that this change is an increase in fat can increase eating disorder behaviors or impact motivation to continue treatment. Education and preparation can help here.
5) Improving blood glucose levels too quickly can also be problematic, as this can result in treatment-induced complications. Slow, steady improvements in blood glucose management is recommended.
6) It is appropriate to include carbohydrates into the eating pattern or meal plan and help clients learn to dose their insulin in response to these foods. Carbohydrates (gluten! added sugar! fruit! juice! challenge foods!) often come laden with messages from friends, family members and diet culture. Clarify with both the team and client how these foods will be included and how to approach these changes. The recommendations for eating disorder treatment may not align with the education clients have received in the past regarding the management of their diabetes or a diabetes meal plan. Anticipate that this will be confusing or frustrating at times and be proactive in providing education and communicating with the team.
7) With type 1 diabetes, insulin doses need to be adjusted based on blood glucose levels and the amount of carbohydrate eaten at a meal or snack. While reading food labels is often discouraged or avoided in eating disorder treatment, this isn’t always feasible for diabetes management. Estimates, exchanges, and consistent meals / consistent doses can all be helpful, but often more precision is needed or wanted. Have open, honest conversations with clients about how to use the nutrition information for appropriate insulin doses. Process what feels difficult or challenging (knowing clients are likely looking at calories, fat or other information on the label as well). Notice when assessing carbohydrate content feels rigid or supports the eating disorder thoughts. Avoid criticism or judgment in your conversations and reduce the black-and-white thinking of labeling foods as “good” or “bad.” Instead, approach the body’s response to foods and their carbohydrate content with curiosity and empower clients to respond appropriately.
If you’re interested in further reading, Ann Goebel-Fabbri has published a book called Prevention and Recovery from Eating Disorders in Type 1 Diabetes: Injecting Hope. Also, On The Cutting Edge, a publication of the Academy of Nutrition and Dietetics’ diabetes practice group released a special issue on eating disorders and diabetes written as a guide and resource for registered dietitians. As always, we are here to help you support your client.
1) Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000; 320: 1563-1566.
2) Pinhas-Hamiel O, Hamiel U, Greenfield Y, et al. Detecting Intentional Insulin Omission for Weight Loss in Girls with type 1 Diabetes Mellitus. International Journal of Eating Disorders. 2013; 46:8 819-825.
3) Colton, P. Eating Disorders and Diabetes: Introduction and Overview. Diabetes Spectrum. 2009; 22:3 138-142
4) Goebel-Fabbri A, Uplinger N, Gerken S, Mangham D, Criego A, Parkins C. Outpatient Management of Eating Disorders in Type 1 Diabetes. Diabetes Spectrum. 2009; vol. 22 no. 3 147-152
5) Goebel-Fabbri, A. Prevention and Recovery from Eating Disorders in Type 1 Diabetes: Injecting Hope. New York, NY: Routledge; 2017.
Meg Salvia, MS, RDN, CDE is the dietitian at Walden Behavioral Care’s Peabody clinic. She sees adolescents and adults in the partial hospitalization program as well as in the binge-eating intensive outpatient program. She is also a board-certified diabetes educator (CDE). She began her career working in research at Joslin Diabetes Center and joined Walden Behavioral Care’s team in 2013. Meg earned a Master’s degree in nutrition from Boston University and a BA in English from Boston College.
Maybe you’ve heard it, maybe you’ve said it: “I want to get better, I just don’t want to gain weight!” Unfortunately, there is no magic wand to make that possible – especially when weight restoration is recommended by your team. Decades of research all boils down to an undeniable fact: emotional and mental recovery happen when physical health is reestablished through weight restoration. Body and mind really are inextricably intertwined.
The silver lining is that once you get to the other side of weight restoration, the emotional and psychological healing that is likely to occur can make weight changes more manageable. Many people even come to appreciate their healthy bodies and have trouble remembering why weight ever mattered so much! I know that might be hard to believe right now, but it’s true, and it’s worth it, so I invite you to take the leap of faith. Here are 5 strategies that might help:
1) Focus on Your Values and Motivators
It’s normal to feel uncertain or ambivalent about recovery in general – especially the weight piece. That’s why it’s important to figure out right at the beginning of treatment why recovery matters to you. These things are going to be harder to remember when you’re having a tough day, so write them down on an index card and use it as a bookmark so that you can keep looking back at it when you need a reminder.
To come up with your list, here are some questions to ask yourself.
• What things do you want to do that the eating disorder gets in the way of? For example, going out for dinner, getting a degree or having a family.
• How has the eating disorder interfered with your values or who you want to be? For example, many people find themselves being less honest or isolating from family and friends, even though they value honesty and relationships.
• What do you dislike about the eating disorder? For example, you might dislike thinking about food all the time, the fact that you’re numb to positive emotions or that you lack energy or motivation for things you used to enjoy.
2) Learn about the Process
When you know that weight restoration is part of your treatment plan, you might focus so much on possible body changes that you start to see almost everything as a sign that your weight is skyrocketing. For example, it is very normal to experience fluid shifts and digestive discomfort that make you feel bloated and uncomfortable. These sensations happen regardless of whether or not weight is changing. It’s also common to believe that, since you are eating more, you must be gaining weight. However, your body is often using the added nutrition to make repairs rather than to restore weight.
The bottom line is, when living with an eating disorder, predictions about your weight are usually skewed. Even if your prediction is somewhat accurate, it’s probably not as dire as you might think. Did you know that weight continues to redistribute itself for 6-12 months after restoration? Knowledge is often power, so in this case, I would recommend talking to your team and asking them to explain what is happening to your body and what to expect during the course of treatment. And do your best to trust what they tell you – they’ve witnessed this process many times before!
3) Turn Your Attention Outward
The more we fixate on something, the more distorted our thoughts and perceptions get. For example, have you ever stared at your computer screen for so long that the words and images become blurry? Similarly, when we focus on our bodies for too long – including its appearance and sensations– our perception can become distorted, thus increasing distress.
Break the cycle by purposefully directing your attention outward, away from your body (but not onto other people’s bodies!). Focus on something in your environment, like the view out the window. Make a list of as many dog breeds as you can think of. Call a friend and ask them how their day is going (rather than talking about what’s upsetting you). Color. Listen to music. Read. Anything that pushes body awareness to the back of your mind.
4) Talk Back to the Eating Disorder
Sometimes, it’s hard to shift your attention away from negative thoughts about your body, fears about weight change and body checking behaviors. When this happens, use your values, motivators and what you’ve learned about the recovery process to challenge the eating disorder thoughts or “voice.” Practice disagreeing with it assertively and repeatedly. The more you do it, the easier it will get.
5) Practice Self-Compassion
Compassion is an alternative to judgment that recognizes difficulties as a universal part of what it means to be human. We experience compassion for each other when we notice that someone is having a tough time, feel emotionally moved by their pain, and therefore respond with kindness, warmth and a desire to help. Do the same for yourself: recognize that you are having a tough time and respond with kindness and warmth. Speak to yourself in a gentle and understanding way, like you might speak to a friend. Try putting your hands over your heart or giving yourself a gentle squeeze (corny, but scientifically proven!). If it’s too daunting to give yourself kind encouragement, you might imagine an inner ally, a positive persona who voices kind and encouraging things to you, drowning out or talking back to the eating disorder’s negative voice.
Of course, none of these strategies is going to guarantee you smooth sailing (that magic wand still doesn’t exist). Recovery is hard work, but that hard work is part of what leads to lasting health and happiness. If you let your team and support system help, and if you draw on these strategies for inner support, you will get through it. And yes, it will be worth it!
Natalie Hill, LICSW, M.Div., is a clinician in Walden’s residential program. Ms. Hill’s professional interests include Narrative Therapy and innovations in Eating Disorder treatment.
Avoidant Restrictive Food Intake Disorder (ARFID) is a relatively new feeding disorder diagnosis that was added to the newest version of the Diagnostic and Statistical Manual. This condition can look a lot like picky eating, but has some very important differentiating characteristics. Amanda Smith, LICSW, Assistant Program Director for Walden Behavioral Care’s Peabody clinic highlights some things that you might not know about this condition.
5 Things You Might Not Know About Avoidant Restrictive Food Intake Disorder (ARFID) - YouTube
Amanda Smith, LICSW, is the Assistant Program Director at Walden Behavioral Care’s Peabody clinic. In this role she oversees the day-to-day care of adolescents in the partial hospitalization and intensive outpatient programs. She works closely with staff, providers, families and clients to help foster a recovery-focused environment. Her career at Walden began in 2010 when she served as a clinical case manager on the inpatient unit for eating disorders. Prior to her current role, she spent time as a clinical case manager in residential and the partial hospitalization and intensive outpatient programs in Waltham. She received her masters of social science administration from Case Western Reserve University.
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