Seven Basic Eating Disorder Recovery Skills

February 24th through March 1st is National Eating Disorders Awareness Week (NEDAW). As a social work intern at the New England Eating Disorders (NEED) program at Sweetser in Saco, Maine, it has been exciting to learn about treatments for eating disorders. Since my time at NEED, I have observed how planning recovery skills is critically important for treatment and have seen firsthand how this can make a difference. In treatment, these skills act as patient coping options and go hand-in-hand with the support that clinicians offer to individuals struggling with these devastating conditions. In honor of NEDAW, here are seven basic eating disorder recovery skills.

1. Ask for help. Encourage patients with eating disorders to take advantage of their support systems and ask for help. For some, asking for help can be difficult to get the hang of, but ultimately it is an important, and often crucial, long-term recovery skill.

2. Expand social environment. Surrounding oneself with positive relationships has been proven effective in the treatment of eating disorders (de Vos et al., 2017). Help a patient to identify current supports and then look beyond these supports to other potential family members, friends, family of choice members, coworkers, etc. to expand the recovery support circle. Having a rich social network is critically useful to finding strength and achieving recovery.

3. Accept valid criticism and reject invalid criticism. Criticism is never easy. When an individual is suffering from an eating disorder, harsh criticism can feel even more devastating. Valid criticism and invalid criticism are quite similar to fact and fiction. Valid criticism (e.g., describing the importance of nutrition for general health and well-being) can provide knowledge to the patient. Invalid criticism, on the other hand, is often hurtful and offers no fact-based information about the importance of nourishing the body and working toward recovery.

4. Reality checking/ mindfulness. When situations are really tough, uncomfortable, or can seem impossible in the moment, encourage patients to take a few moments to ground themselves and focus on the facts. Ask patients to take a moment to put their feet flat on the floor, take a few deep breaths, and focus on their sensory experience. Ask patients to remind themselves of the realities of the moment. If this is difficult to do, ask a patient to consult with a trusted confidante to explain a situation and test the reality of their appraisal of the situation.

5. Assertiveness. Encourage patients to not only be assertive with others, but also with their eating disorders. The individual is in control of their recovery and it is important to let the eating disorder understand that. Additionally, allow patients the privilege of being assertive about their needs when communicating with others throughout the duration of their recovery.

6. Boundary setting. Encourage patients with eating disorders to set distinct boundaries around people and/or situations that feed into their eating disorder. Hurtful words or actions from others have the potential to induce feelings of toxic shame, making individuals feel worse about their bodies and emotional state. Setting appropriate boundaries, particularly during triggering times, and engaging in proactive problem solving to identify these boundaries ahead of time is paramount for relapse prevention.

7. Distress tolerance. Patients with eating disorders are practicing distress tolerance every time they sit down to complete a difficult meal or snack, as they are confronting significant fears. It is important to survive very anxiety-provoking situations during recovery. Once one feared situation is confronted repeatedly, this often generalizes. As therapists, allowing patients to experience this distress and tolerate it is at the foundation of most evidence-based treatments for eating disorders.

References:

De Vos, J.A., LaMarre, A., Radstaak, M. et al. (2017). Identifying fundamental criteria for eating disorder recovery: a systematic review and qualitative meta-analysis. Journal of Eating Disorders 5, 34. https://doi.org/10.1186/s40337-017-0164-0

Briana Ciallela is a clinical intern for the New England Eating Disorders program. She has her Bachelor of Arts degree in psychology from Bard College and is currently a Master of Social Work candidate at the University of New England.

Encountering Bullies who Target our Bodies

by Dr Kathleen Hart

At some point, someone will negatively comment on your teen’s body, whether it’s intended bullying or not, and it’s important to arm them with the skills to handle it. Dr. Kathleen Hart, a licensed psychologist specializing in the treatment of eating disorders, recommends discussing this with your child well before their teen years. “Bullying comments about bodies are like verbal arrows. If you prepare your child that one day, they will encounter someone who will shoot a verbal arrow in their direction by criticizing their body, then they will be better equipped to handle it.”

But how? Dr. Hart recommends making the clear distinction that these words are verbal attacks. “Coaching your teen to think, ‘Oh I’ve just been targeted by a bully’ rather than ‘So-and-so thinks I’m fat’ will prevent bullying comments to seep into your child’s emotional life and gradually erode their body-esteem.”

Top 10 things a medical provider should know about eating disorders: from a patient's perspective

by Patrice Lockhart, MD

10. Don't judge a patient by his/her size. Think function, not form.

9. If a patient's family is worried about weight change, listen. 

8. "You look great! You've lost weight!" is a sure way to encourage eating disordered behaviors.

7. Recognize the impact that your own biases toward thinness affect your patients. If they feel that you treat them differently because of their weight, they are likely not going to be honest with you.

6. Do not assume that if lab values are normal, a patient's health is "fine." Look to vital signs, and especially behaviors: binge eating, restrictive eating, and purging of all kinds.

5. Purging is not just vomiting. It includes use of diet pills, laxatives, diuretics, and compulsive exercise.

4. 1 out of 3 patients with eating disorders do not get the help they need. Intervene early to make a difference.

3. If a patient presents to you for medical treatment of an eating disorder, see them often. This let's patients know you take them seriously.

2.If there is not progress in a patient's wellbeing, refer to a higher level of care quickly. It is not adequate care to let a patient continue in dangerous behaviors.

1.Screen for eating disorders as you would for substance abuse, sexual activity, and other general health issues. In our culture, you will be surprised at how much pressure there is that leads to eating behaviors. 

10 Suggestions On How to Improve Health Class From a Registered Dietitian Nutritionist

by Amy Taylor Grimm, RDN, LDN

Over the course of the past 17 years that I’ve been in practice, I can’t tell you the number of clients whose eating disorders were triggered by the nutrition unit in health class. There are, of course, other versions of health class in the adult world (podcasts, seminars, doctors’ appointments, even advice from dietitians) that can send someone who is at risk for an eating disorder in to a full-blown episode.

 Here are the top 10 components of health class curriculum that I would change, if I could, that think would save people from going down a very painful road:

 1)   Stop demonizing sugar. Sugar is our number one fuel source - without it we die. I realize that refined sugar is added to many foods these days, however, if we teach children to listen to their hunger signals, legalize all foods, provide variety, and provide opportunities for pleasurable activity, sugar will not be a problem.

 2)   Stop doing diet recalls.  I had to do this in college – the computer program told me that I needed to lose a significant amount of weight and I was at high risk of cardiovascular disease. I was both very active and eating a pretty well-balanced diet at the time – I was horrified! These types of projects cause many people shame and only increase secretive eating disorder behavior. If teachers want to make sure that kids are getting in enough nutrients, how about doing a tally of how many fruits and vegetables or calcium they get in in a week? That way the conversation can be on how to fit in more, not making them feel embarrassed by what they are eating.

 3)   Promote joyful activity.  By focusing on how many hours people should be exercising, we make some people rely on numbers, not on how fulfilling an activity is. Also, by hooking exercise onto weight loss, which many health professionals do, it makes some people give up if they aren’t losing. Our size does not matter in our health and it is beneficial for everyone to participate in activities we like regardless of their size.

 4)   Look at the big picture. Our bodies don’t have daily cut-off times. If we don’t get the Recommended Daily Allowance of protein in on Monday, we didn’t do any damage. Our bodies actually work on averages. As long as you get a variety of foods in on a two week time frame, you’re good to go. This holds for exercise as well – if you didn’t exercise on Thursday, you don’t need to “cut back” on calories that day. Sometimes extra activity on Monday might not manifest as being hungrier until Wednesday. You just have to listen to your hunger cues, they will never steer you wrong. Which brings me to #5…

5)   Teach the students how to recognize hunger and fullness. The number one gold standard of how much and when you’re supposed to eat is your hunger cues. Many people have ignored them for so long that they rarely feel them anymore. Many of my clients report only ever feeling stuffed or starving – nothing in between. Ask the students if they know where their stomachs are and what it feels like when they are hungry (growling, light-headed, “hangry”, etc.). Advise them to not wait until they are starving to eat, if possible, so that they don’t overload their bodies, and to honor the hunger cues when they come so that they can fuel their bodies appropriately.

6)   Teach students to recognize what they are hungry for. Contrary to popular belief, if you eat what you are wanting, you will not be eating M&M’s and chips all day. You pretty quickly begin to crave other things as long as it’s ok to eat M&M’s and chips. If it’s not because “junk food” isn’t allowed in the house, there is shame around having it in the culture of the family, or it is in any other way “bad”, then the drive to eat it when it’s available goes up. But if this is not the case, most people desire a wide variety of foods from all different groups. If we don’t eat what we want, then we don’t feel satisfied and we usually end up eating what we wanted afterwards anyway.

 7)   Always add, never take away. If you want them to eat more fiber, tell them what their goal is and how to get there. If you make processed, low-fiber foods bad, then some of the students will feel some level of guilt when they eat them, which can manifest in two ways: 1) They will overeat them in secret, or 2) They will restrict them and become very rigid about their food. It will all balance out normally if we stop taking things away.

8)   Integrate cooking class, or at least a food preparation class. Lots and lots of my clients aren’t interested in cooking, not only because of their eating disorders, but because they have never experienced any kind of advanced food prep. Bring in new foods, try ethnic dishes, experiment with herbs, have contests, anything to get their creative juices flowing. Oh yeah, you can try juicing too!

 9)   Talk about your own eating (if it is normal and you are comfortable). Kids look up to their teachers, believe it or not.  A really big indicator of eating disorders is how parents and other role models eat and talk about eating and their bodies. If you talk about how wonderful the new Ben and Jerry’s flavor that you had last night was, with no guilt, the kids will hear you and get that there’s nothing to feel guilty about.

 10)  Lighten up. We all need to chill out a little about the “obesity crisis” and see that it might not be what we think it is. There is evidence that being a larger-sized person is not necessarily a bad thing and, in fact , can be healthier than being on the underweight side. Lack of activity and poor nutrition do contribute to disease, and weight can correlate with that, but is not necessarily the cause. We all can be healthier, no matter what our size if we eat intuitively, regularly move our bodies in a way that we enjoy, and pay attention to our mental health.

We just need to pay more attention to what is on the inside.

Stop Policing My Daughter's Appetite

'You're not going to eat all of that, are you?' said a stranger in a café to my four year old daughter Violet. 

Violet was tucking into a slab of chocolate cake with ice cream on the side. The woman meant her comment to be friendly, but it was the only thing she commented on to Violet.

Violet is in kindergarten and already people — even complete strangers — are judging her food choices, intimating that she should distrust these choices and that her appetite should be ignored.  

What’s worse, Violet is learning that women policing other women’s appetites is a great conversation starter, or even a bonding ritual.