Recently, I created a list of questions to ask when vetting an eating disorder treament program to see what they actually provide. I thought I’d share this with all of you in case you’re looking for a higher level of eating disorder treatment.
Here are some tips you might find helpful when working with clients with Eating Disorders, or Disordered Eating:
1. Find a registered dietician who specializes in Eating Disorders. It is important that your belief systems and theirs align when working together to treat a client. For example, most people in the eating disorder recovery field believe that there are no "bad" foods and we work with clients to neutralize food. However, some people believe in "abstinence" from certain foods or food groups. When I am looking for a dietician, I make sure that they're not of the school of thought to tell my clients to restrict food groups as it would go against the work we are doing clinically.
2. Buy large desk calendar and different stickers and create a behavior chart for meals and snacks well done according to their meal plan. Celebrate successes elaborately!
3. If age appropriate, work with parents on making "no Foods bad". Everyone in the family can join in on recovery by coming together to share with all food groups.
4. If age appropriate, look into the Maudsley Method for re-feeding process.
5. Work with your client to create an art project around beautiful people, models, actresses, friends or family and others in Pinterest or print outs who are not super skinny. Process what they find beautiful about these people. Encourage clients to post up these images on their wall so that they get used to seeing ideal beauty images and other than emaciated models.
6. Make a list of all clients fear foods and safe foods and medium foods and use CBT to debunk myths of fear foods.
7. Eat 'normal meals' together in session - especially with fear foods - exposure therapy.
8. Find studies that show that whatever fear foods are - are not 'bad' i.e. - sugar is not as evil as everyone says.
9. Use ego state work to find out which 'parts' in clients psyche are telling them not to eat and have conversations with them using Gestalt Chair Work.
10. Use the books Life Without Ed by Jenni Schaefer as a guilde book, everyone involved should read and the book 8 Keys to Recover from an Eating Disorder by Carolyn Costin can be used for treatment and interventions as well.
11. The therapist can have client draw their body in the size and shape she believes it's in, then have therapist actually trace clients body and process the difference.
12. If there's one body part the client is upset about like their waist, have client draw what they believe is their waist size, then use a string to measure (not using numbers) the actual size and trace THAT onto the paper and process the difference.
Hope this helps!!
What else do you use as interventions for clients? Please comment below!! As always, if you have any questions or concerns, please contact me at 610.314.8402 or through www.TiffanySpilove.com
A brief update from the author:
I wrote the following post just over 6 years ago. I had been fully recovered from bulimic symptoms for about 4 years at the time. It’s now been 10 years of recovery and I still deeply believe in all of the words I speak in this piece. The only thing that’s changed is that I feel even further away from experiencing desires to binge or purge. There was a time when it was hard to imagine feeling completely comfortable around food, easily stopping when full, and not thinking about the ice cream in the freezer constantly. I hope this article helps some of you! Be brave. Recovery is totally possible! - Melissa
My Journey With Bulimia
December 6, 2010
About ten years ago I developed a condition known as bulimia. I never would have guessed that a smart girl like me would struggle with something like that. I knew better. I had learned about eating disorders when I was younger and could never make sense of why someone would force themselves to vomit after eating or avoid eating all together.
I think very differently about eating disorders today. You can be intelligent, self-aware, and informed about eating disorders and still struggle with the “disease.” I remember the first time I displayed signs that I was at risk for developing bulimia. I was reading a book about how bad refined sugar was, and I was doing an excellent job of eliminating it from my diet—that is until I was tempted by a birthday cake brought into work one day. I decided to treat myself to a slice, and as I was finishing it, I felt deeply concerned about how the sugar might be harming my body. I don’t know what made me think of it because I had never chosen to throw up food before (nor did I know of anyone who had), but I quickly went to the bathroom and vomited in a stall.
I felt much better after getting rid of the sugar and didn’t think of it again until a year later. I had begun a big transformation in my life. I was starting to question my faith, my choice of career, the reasons for my failed romantic relationships, etc. I decided to go to counseling, and after a few sessions the counselor asked, “Where is Melissa?” I didn’t understand what she meant, but after some back and forth, she finally explained, “You tell me everything you think you SHOULD do and SHOULD want, but you don’t tell me how YOU feel and what YOU want.”
No one has said anything that has impacted me more deeply than that statement. I realized that I had become so good at assessing what I thought other people wanted that I had become disconnected from my own desires, feelings, and opinions. It’s like they were crowded out by the noise of all the other expectations and demands I thought I had to meet.
After that session, I started concentrating on my inner world and made a lot of effort to to connect more deeply with myself. As part of that exploration, I went back to dance class. Dance was an innate joy for me. It was my childhood passion, something I knew that I didn’t do to please anyone else. I hoped that dance would remind me of what it was like to feel.
And it worked. The feelings that dance inspired in me became recognizable in other areas of my life. In an attempt to follow this, I started spending more time alone so that I could learn to hear my own voice. I stopped going to church so that I could figure out what I really believed about God, without pressure from others. I also got a second job and began saving to spend six months in New York studying dance. New York was a place I had always wanted to live and I wanted to gift myself with the opportunity. And lastly, I decided to finally lose the weight I had gained since high school. For the first time, I was choosing to take my dreams seriously and have confidence in my ability to achieve them.
Several months later the pounds were coming off and I felt amazing. I was losing weight in a healthy way and sticking to a diet plan longer than ever before. I felt like I was discovering my real body: lean, healthy, strong, and energetic. I felt beautiful inside and out.
Somewhere close to my goal weight, I gave in and ate something that I knew was higher than the amount of calories I needed. I became afraid. Seeing myself eat food that was not in my plan made me fear that I was stepping back into old behaviors. In the past, I would stick to a diet for a little while but would always end up giving into temptation, promising myself that I would start again the next day. It was a bad cycle that I didn’t want to continue. Not only that, but I was falling in love with the “new” me, the me that was living from her heart, the me that was committing to her goals, and the me who was coming out of her shell and no longer hiding under extra weight. I felt more confident. I was getting attention from boys, and I was interacting more with people. I didn’t want to lose those things. That’s when I remembered my experience with the sugar elimination diet. I realized that I could just get rid of what I ate in the bathroom and my problem would be solved. So I did.
I never imagined that I would do it again. I thought it was a one-time thing. But it did happen again. Not often, at first. But every time I felt unsure about the calories I had consumed in a meal or I knew that I had too many, I ultimately found myself in the bathroom.
At one point, I became concerned that I might have an eating disorder. I remember going online and looking up the symptoms for bulimia. The criteria noted that an individual must have a certain number of symptoms to be diagnosed. Although I thought I might need help, my symptoms didn’t match enough of the criteria. I wasn’t bingeing at all and I wasn’t vomiting enough over the course of a week. As a result, I worried that I would not be taken seriously, so I was too embarrassed to seek help.
Eventually the symptoms did grow. It became harder to vomit if I didn’t eat enough, so I started to binge. My bulimia began to look very “textbook.”
In May of 2001, I moved to NYC. I accomplished some amazing things and had some wonderful experiences. During that time, I had periods when I went for months without symptoms and others when I vomited every day. I eventually went to counseling again, and during those sessions, my counselor offered me one important insight about bulimia. She simply said, “Maybe you’re not ready to give it up.” For the first time I considered the notion that I could give myself permission to continue. What a scary idea, but she was right to suggest it.
From the time my symptoms began, I was resistant to them. After every purge, I promised myself it would be the last time. My mind was filled with figuring out ways to keep it from happening again. By accepting bulimia’s place in my life, I was able to learn from it and understand why it was there. Since my mind was free from thoughts of guilt, criticism, and resistance, I had space to feel the emotions that bulimia was trying to bring to the surface. I started recognizing the feelings I felt when I would binge and purge and realized how they were connected to other challenges in my life. When I saw the connections, I could start resolving the problems in other ways.
It took awhile, but I eventually let bulimia go. I would stop for several months, have a bout, then stop for many more months, have another bout, then stop for a longer period of time, etc. It’s been over three years now, maybe almost four, since the last period of symptoms.
I believe my bulimia represented a step toward healing. It often felt that people around me viewed bulimia as a problem, as a step backward, as something I was doing wrong. At first, I joined them in this conclusion. But bulimia came into my life when I was beginning a fight to be true to myself and resist the external pressures around me to please others, to follow another’s lead, to do what other people thought was good rather than what I felt was good. I didn’t know how to say “no.” I didn’t know how to negotiate. For years I had been taking in, absorbing and adjusting to what others wanted so that I could gain their approval and respect, ultimately depending on them for assurance and confidence. Simultaneously, I ate all the time. That’s how I gained weight in the first place. I just consumed. I dealt with my problems by eating. I couldn’t say no to food either.
I was finally coming to a point in my life where I wanted to trust myself, but I was scared. It was a battle. I was taking food in (symbolically, others’ opinions, desires, and expectations) but realized that I didn’t want it. So I would push it back out. I was starting to say no and bulimia represented a violent fight inside me.
It’s hard to be yourself in this world. There are a lot of demands, many that are indirect, and it was hard for me to resist the impulse to meet all those demands. Food was my vice, so it makes sense that my relationship with food symbolically paralleled my relationship with myself and with the world.
I think my bulimic episodes ended when I started trusting myself more and worrying less about others’ opinions, worrying less about someone being upset if I told them “no.” I knew that I didn’t want to continue bingeing and purging because the health risks weren’t worth it to me. So, eventually I chose to stop, probably when I had the internal strength to make that choice for myself (rather than just to appease others). Much of it was learning how to have boundaries. Just like I had to learn how to have boundaries with people, I had to learn how to have boundaries with food.
Does this mean that I have perfect boundaries with people now, that I never overeat, that I trust myself completely all the time? No. I still struggle with these things, just like everyone does. But the experiences I had while dealing with bulimia transpired into major changes in my life, changes I certainly benefit from now. My boundaries are much stronger and clearer, and I have more awareness of when I am compromising who I am. In fact, if I ever have the urge overeat or vomit, and I do sometimes, it’s a great clue to me that I’m not dealing with something in my life the way that I need to. I know that now, so I can take a step back, look at the problem, and figure out a more productive solution. It’s funny, because that solution often means asking for help or making myself more vulnerable with someone (letting someone in), or saying what I feel and risking possible rejection - again, all connected to boundaries.
Bulimia is complicated and very layered. I haven’t addressed all of those layers here. Furthermore, I can only speak from my own experience; I don’t mean to represent others’ experiences. Over time, I’ve learned that people’s stories and the reasons behind their personal challenges are varied and don’t all fit into a neat little defined box. But I do believe that for many people, symptoms of bulimia actually symbolize an attempt toward health, the body reacting in order to make something right. I believe the symptoms are symbolic of the internal fight of an individual trying to find their voice, to find confidence, to look for a way to move out of whatever problem they have been dealing with, a problem that existed before symptoms of bulimia showed up. It’s never just about bulimia, it’s always about something much deeper. I think that many individuals with bulimia are trying to figure out how to finally have boundaries—with themselves and with the world. If they can find support to understand and transition through it, support to trust themselves, then the stage after bulimia can be fuller health, greater self-esteem and confidence, and healthier boundaries.
Melissa King, LMHC is now a psychotherapist in New York City who works with women, gay/bi men, and couples in the first 10 years of a relationship. Find out more about Melissa here. https://www.myheartdances.com
If you have any questions or need support, please feel free to call me at 610.314.8402 for a free 15 minute phone consultation.
Please comment below and tell us your story !
I know, I know, it sounds TERRIFYING! Yes, I'm serious - you will not die from eating food in a restaurant ... I PROMISE! It might FEEL like you'll die, it might seem like you'll gain a hundred pounds just from eating the food that is cooked for you back in that kitchen you can't see.
As my friend and colleague, Natalie says, "there aren't calorie ninja's back in the kitchen adding calories to your food"! I understand the fear - I get that allowing somebody else to prepare your food is giving up control in a way that might not feel safe for you just yet. Here's the rub, though - even though it might be hard to admit, I KNOW you want to be able to participate in experiences that involve food. You WANT to be social. You want to hang with your friends while they get frozen yogurt or try the food at the new cafe. You want to live your life again... it's just that ED forbids it. Here are some helpful tips for you to get more comfortable with dining out:
When you find yourself feeling fear about eating in a restaurant, it's sort of like a phobia - a very heightened anxiety around something specific. The way to deal with and cure this type of phobia is through exposure - WITHOUT - re-traumatizing yourself. So you don't want to push yourself to take it all on without practicing and getting comfortable with various aspects of it first.
You might want to enlist the help of your therapist, friend or family member. Tell them some food options that you consider safe. Start small.
It's better to have success with something less challenging than to get overwhelmed with something scarier.
Your support team member could either get you food from a restaurant or give you food that they made without you present. Or if you need to start even smaller, you could watch them make your meal so you know it's safe. Eat with them. Notice your feelings. Use anxiety reduction and grounding techniques. Keep breathing and do your best. Keep practicing this step until your anxiety stays below a 7 on a 0-10 scale with 10 being the worst anxiety you've felt and 0 being no anxiety at all.
Increase the challenge slowly
Once you get comfortable with eating meals made by others, up the ante. If you're still not ready for restaurant dining, try getting take-out or try eating foods you didn't see being prepared. Use an affirmation like "This food is safe and nourishing; I am safe and I can eat this food". Make sure you start off each experience with some breathing and relaxing techniques so that you don't associate fear with the experience.
If noise bothers you, choose a restaurant that's quieter or a time of day that's less intense like lunch. See if you can get a table that's against a wall, in a corner or in a quieter area of the restaurant. This reduces over-stimulation and feelings of vulnerability.
Have a plan
In earlier recovery, it's helpful to have a plan. If you know which restaurant you'll be going to, look up their menu online. Work with your therapist or dietician to determine which menu item you'll be selecting. Most restaurants have portions that are significantly larger than the exchanges on your meal plan. If this is the case, you could anticipate eating half the meal. One tip is to ask for a to-go box at the beginning of the meal so that you can put half away for later and just focus on what's on your plate.
Go with someone supportive
This experience is hard enough, don't add to it by going with someone who doesn't "get it" or tries to sabotage your recovery. Some therapists or dietitians will conduct sessions at the restaurant with you so that you can talk through it as it's happening. If that's not an option, or you're ready for the next step, choose a member of your support group who understands your recovery. Let them know the plan beforehand and maybe come up with a code word in case you need to abandon the mission.
Remember to breathe
Keep taking those deep belly breaths and know that this is just one meal. One meal won't make you fat. If you notice yourself starting to get overwhelmed or anxious, just come back to your breath. While you're eating, try to focus the conversation on something else like the weather, the new movie just out or anything fun. Take a sip of water, feel your feet. You got this!!
Do's and Don'ts:
- Keep the conversation light
- Have some topics in mind to talk about while you're eating
- Get the food down
- Chew thoroughly
- Focus on the conversation, the beautiful setting or anything but the food and body
- Wear comfortable clothes
- Stay at the table for the entirety of the meal
- Set your pace to about 30 minutes to complete your meal
- Count the calories
- Compare your dish to anyone else's
- Body check while you're at the table
- Talk about food, weight, exercise or anything triggering while you're at the table
Keep your eye on the prize!
This experience is not just about today or next week. You are engaging in this exercise so that you can enjoy your life - so that you can HAVE a life! Spending all your time in isolation, feeling lonely, not participating in social events is no way to live. Remember that you are doing this so that you can be happy and free of your eating disorder.
One day at a time
One meal at a time
One bite at a time
You CAN recover!! Recovery from an eating disorder is not a linear process. It goes all over the place, it's messy at times and sometimes you need to take 5 steps backward so that you can get good 2 steps forwards. Even one success is worth celebrating, so give yourself credit for EVERYTHING you do right.
If you're still feeling anxious about dining out and you'd like some support, I'd be happy to schedule a time to help you reach your goals. Contact me now at 610.314.8402 to learn more about how to dine out with an eating disorder. Please feel free to share this post with anyone who is looking for help with eating and body issues.
Good luck and enjoy!!
If you have any questions or need support, please feel free to call me at 610.314.8402 for a free 15 minute phone consultation.
Please comment below and tell us your story!
Holidays may be happy and exciting for some of us and for some, they are also very stressful. Food is definitely a big deal during the holiday season for most people. Gym memberships go up afterward, people are often found dieting or “cheating” on their diets. Some binge, some restrict, some over-eat and some fall apart. I’d like to help you find a bit of peace from my corner of the world during this time when Christmas is fast approaching. If you haven’t already read them, check out some free tips on normal eating, getting grounded, reducing anxiety, navigating the grocery store… They should prove useful for you as well.
Here are some tips specific to Christmas:
1. Create an intention for this holiday
Remember that Christmas can be about celebrating spirituality. It can be about enjoying family or giving. It can be about service, love, bundling up on a cold day or anything you want it to be!
What would you LIKE your intention to be for Christmas this year?
Find a purpose and go for it. If your purpose is about service, think about how you’d like to be of service. It could be as simple as helping to set up or clean up the party. You could help the less fortunate through a soup kitchen or donating gifts to children who need them. If you’d like your purpose to be about reading a great book and drinking tea, then go for it! Any intention you’d like for Christmas is yours to have!
2. Get Grounded:
BEFORE you leave your house. Think about what grounds you? Do something that feels very grounding for you and set an intention to keep checking in with yourself during the day. One of my favorite ways to get grounded is to ask myself
“Where are your feet?”
– then look down at them; wiggle my toes, feel my feet on the floor or in my shoes. When I do that, I can rest assured that right here, in this moment, I am safe. In this moment, where my feet are, I am okay. Here are some other examples of grounding activities:
- Prayer and meditation
- Aromatherapy: earthy smells like cedar, bergamot, and pine can be particularly grounding
- Coloring mandala’s or other coloring
- Going for a walk
- Make a list: of anxieties, gratitude’s or plans, etc.
- Have a bit of a plan for the day – perhaps write it down in the morning.
3. Create Foods You Love
Try a new recipe you've been thinking about. Bring safe foods for you to the event you go to so that you have at least one option while you're there.
4. Don't Push Yourself
This is not the time for major challenge meals. While I encourage you to taste some of every food you're interested in, if you know that a certain food will completely set you off, just avoid it for now. Challenge meals are best done with the support of a therapist or a support community. You can practice eating challenge meals until they're no longer as challenging. Once you've accomplished taking the power out of the challenging foods, THEN you can incorporate them into your holiday festivities. In this instance, it might be better to be safe than sorry - don't push yourself so hard that you find yourself wanting to act out in a binge-purge cycle. Support yourself in enjoying Christmas as much as possible rather than pushing yourself into discomfort.
5. Contain the food
Do your best to eat meals at the normal times you usually eat them. So instead of skipping breakfast and going to Christmas hungry, eat your normal breakfast.
When you get to your event, check into your hunger cues.
On a scale of 0-10, with zero being extremely starving, 5 is having a light sense of satisfaction – being neither hungry nor full and ten being the most stuffed you’ve ever experienced. How hungry are you? Aim for letting yourself empty out to a 2-3 before eating a meal. See if you can stop eating at a 5-7.
Once you are hungry, rather than grazing on all the different foods, make a plate.
Allow yourself to put at least a little bit of each food you love on the plate or foods you’d like to try.
Skip the foods that don’t interest you much. Sit down and really savor the foods you chose. Check in with your hunger and satiety signals a few times while you eat your plate. Once you are satisfied, tell yourself that you can have more when you are hungry again and follow through. Making a practice of using hunger and satiety cues is extremely helpful in finding balance with food.
6. Keep Your Boundaries
People tend to project their OWN food and body issues onto others’. So if you notice yourself engaged in a conversation with someone who’s trying to talk you in or out of eating or commenting on your body, take a step back.
Check in with yourself and see what YOU NEED, rather than what this person is trying to get you to do.
Saying you need to use the bathroom is always an easy out to give yourself some time and space to check back in with yourself and get grounded. Take some deep breaths, splash some water on your face and ask yourself what you need in that moment to take care of yourself before you leave the bathroom. Here are some examples of things you can say to people who are pushing you:
- “No, thank you”
- “I’m okay right now”
- “Yes, I’m going to enjoy this food right now”
- “I’m not hungry”
- “I’ll let you know when I’m ready for ...”
- “I’d rather not discuss my body with you”
Practice saying these boundaries out loud BEFORE the holiday, so that when you’re in the moment, they flow easily and effortlessly.
7. Ask for Help
Enlist a member of your support group to be ‘Holiday Buddies’ to practice what I call ‘Book Ending’: Have a few agreed upon times you with check-in with one another throughout the day – perhaps before, during and after. You could plan to call or text one another to report how things are going. If you don’t hear from your buddy, shoot them a text to see what’s going on. In this way, you have another person who has your best interest in mind to be accountable to. This practice is also helpful in getting your mind off yourself and your own difficulties.
Remember that Christmas is only one day out of the year. Breathe into the gifts you receive whether they are material or spiritual, gratitude or emotions - breathe into this experience of life and know that you can get through this. You don't need to be perfect and neither does your holiday. When you feel yourself getting overwhelmed, focus on your breath. Remember you can start your day over at any time.
I hope you've found these Christmas tips helpful. If you're still feeling overwhelmed, please feel free to give me a call at 610.314.8402 - I'd be happy to help.
Merry Christmas from Tiffany Spilove Psychotherapy in West Chester, Pa!
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