Dietitian Seasonings &
Therapist Reasonings
Introducing the
Podcast
Welcome..
to the show notes for Jill and Meredith's Podcast: Dietitian Seasonings & Therapist Reasonings!
Whether you are just starting in the field of eating disorders or a seasoned, wise clinician, everyone needs support, guidance and advice once in awhile.
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What is our podcast about?
This podcast is hosted by dietitian Jill Sechi and therapist Meredith Riddick, eating disorders specialists supervisors with A Collaborative Approach. This podcast is intended to support, educated and validate clinicians in the eating disorders field; emphasizing the team approach as best practice and encouraging evidence based care.
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Season 1
Episode 0: In The Beginning
In this episode (episode 0), we introduce therapist Meredith Riddick and Dietitian Jill Sechi, certified eating disorders specialists supervisors with A Collaborative Approach. Meredith and Jill share their story of when they first met and began collaborating together in the field of eating disorders. Meredith introduces Jill and Jill introduces Meredith elaborating on work experience, time in the field and how they developed their expertise. In this brief episode we hope you get to know Jill and Meredith a little better as they begin their journey in the podcast world.
Episode 1: Give Me One Good Reason to Collaborate
“Team communication and collaboration are essential to prevent confusion and misunderstandings and to reinforce a unified message (Alexander & Treasure, 2012, p.146)." In episode 1, therapist Meredith Riddick and Dietitian Jill Sechi dive into their take on a collaborative approach and why it is important to promote a unified message. They talk about how having a collaborative team approach can be very beneficial, and how not having a collaborative approach can end up being problematic. Meredith and Jill also go into the different challenges when trying to collaborate with different clinicians, and how to face those challenges head on while still "staying in your lane." They also discuss the different themes of collaborating and how to utilize these themes in your practice daily. We hope you get an understanding of why we are A Collaborative Approach, and hope to spike your interest into our next Episode 2: Part 1 of the Ten Commandments.
Episode 2: Part 1 of the Ten Commandments
In this episode, Meredith and Jill talk about their first five commandments of collaboration. If you are thinking about implementing a more collaborative approach in your practice, this is a great episode to listen to. They talk about five different "commandments" that they live by in their private practices in order to maintain a healthy relationship with the client and other clinicians on the treatment team. Meredith and Jill go into how communication, respect, honor, and honesty are all used throughout the commandments. They go into what each commandment means, importance and how to avoid "disobeying" each commandment. We hope that you leave this podcast with a little direction on how to begin your collaborative approach, but we hope to give you more direction in our next Episode 3: Part 2 of the Ten Commandments.
First Commandment: Thou shalt talk to one another.
Second Commandment: Thou shalt not allow false testimony of other providers.
Third Commandment: Thou shalt honor treatment team as best practice.
Fourth Commandment: Thou shalt not covet each other's profession.
Fifth Commandment: Thou Shalt not commit treatment team adultery.
Episode 3: Part 2 of the Ten Commandments
In this episode, Meredith and Jill talk about their second half of the Ten Commandments for Collaboration. They continue to go into what each commandment means, , how to apply, and how to avoid "disobeying" each commandment. If you missed the first half of the Ten Commandments of Collaboration Meredith and Jill talked about those in Episode 2. If you have already listened to the first five, give this podcast a listen to get the full picture and learn how to put all the commandments together. Meredith and Jill strongly believe in and practice these Ten Commandments for Collaboration, and use them as their backbone in their practices. Stay tuned for Episode 4 as they dive deep into Body Image from a dietitian and therapist perspective.
Sixth Commandment: Thou shalt watch out for treatment bias.
Seventh Commandment: Thou shalt not misuse the name of Recovery.
Eighth Commandment: Remember major events and keep them holy.
Ninth Commandment: Thou shalt not throw in the towel with other providers.
Tenth Commandment: Thou shalt not steal the thunder of other providers.
Episode 4: Body Image, Diving Deep
In this episode, Jill and Meredith dive deep into body image and even divide into three different parts. They both discuss body image when working with clients, their own body image, and what the treatment provider roles are and how to address them. Meredith and Jill both go into the attitudes and emotions around body image; when to address body image in your sessions, what to engage in, and how to engage from a dietitian's and therapist's perspective. When discussing their own body image, they talk about how they personally deal with body image in the client/clinician relationship. They also go into clinician's roles and the education that is helpful to provide depending on their scope of practice. Do you as a clinician know how to handle body image? Is it realistic to always have a positive body image? Listen to our take on body image and how we as seasoned clinicians deal with body image in the field of eating disorders.
Episode 5: You're fired!
How do you feel when a client doesn't respond well to your practice? Have you ever been fired by a client? If so, how has this made you feel? Many can feel disliked, which is a feeling that no one wants to feel. In this episode, Jill and Meredith discuss how they feel and deal with clients that "fire them." They go into their own experiences and how they deal with a client moving on from them, or even maybe a client never clicking with them in the beginning. They talk about signs that they look out for based on their own experiences, that usually lead to being "fired" by their client. Tune in!
Episode 6: Tigger and Eeyore
Tigger and Eeyore? You may be wondering what in the world this episode could possibly be about. Instead of Tigger and Eeyore, could we be talking about anxiety and depression? In this episode, we go into an overview for how these topics show up for our clients. Meredith talks about the diagnostic criteria for anxiety and depression, she explains the differences in both of them, and goes into what to look for in sessions. Jill goes into how she sees anxiety and depression and how it can affect a client's behaviors around food. Did you ever wonder what a therapist might know verses what a registered dietitian might need to know when having clients that struggle with anxiety or depression? If so, tune in to Episode 6 and let us know what you think!
Episode 7: Let's Talk about Sex, Baby!
In this episode, Jill and Meredith talk about how eating disorders can impact intimacy. They discuss both physical and emotional intimacy as well as multiple examples of intimacy such as sex, being open and honest, or being vulnerable with friends and family. Intimacy concerns can come up in multiple ways with clients and you may be unsure how to approach it. Jill discusses how intimacy concerns can show up in nutrition sessions and the impact it can have on the client's relationship with food and or their body. Meredith talks about how it can appear in therapy, when addresses it in session, as well as and attachment therapy and how it can be used to predict a client's adult relationships or a client's eating patterns. How can a client's relationship with food mimic their relationship with people? How does a dietitian handle intimacy concerns? What about a therapist? Why is it helpful for a therapist to share intimacy concerns with a dietitian or other members of the treatment team? How can a therapist collaborate with treatment team members regarding this topic without disclosing too much information? Listen to Episode 7 to get answers to these questions and learn how seasoned clinicians treat intimacy concerns in the field of eating disorders.
Episode 8: Part 1 Are we a little OCPD about Dxs in Tx?
Have you ever had a client feel like they are being labeled or judged when they are diagnosed when an eating disorder? Do you tell the client what eating disorder they are diagnosed with? Do you know the criteria for all types of eating disorders? In this episode, Meredith and Jill discuss the importance of diagnosing a client with an eating disorder and basic criteria that distinguishes anorexia nervosa (AN), bulimia (BN), and binge eating disorder (BED). The more you know the each eating disorder diagnosis, the better you are to serve the client as each diagnosis has a different evidenced based treatment. Often we see that a client struggling with bulimia gets misdiagnosed with binge eating disorder. Why? What role does a dietitian play in diagnosing eating disorders? This episode will answer those questions and so much more in episode 8. In episode will focus on AN, BN, and BED, but stay tuned for episode 9, where they will continue this discussion on other specified feeding or eating disorders (OSFED), avoidant restrictive intake disorder (ARFID), and unspecified feeding or eating disorders.
Episode 9: Part 2 Are we a little OCPD about Dxs in Tx?
In episode 9 part 2, Jill and Meredith continue the discussion about different eating disorder diagnosis, focusing on other specified feeding or eating disorder (OSFED), avoidant restrictive intake disorder (ARFID), and unspecified feeding or eating disorder. This could be a possible diagnosis your client may receive if they are struggling with an eating disorder, but doesn't quite fit the diagnostic criteria of anorexia nervosa, bulimia nervosa, or binge eating disorder. Examples may include atypical anorexia, purging disorder (without bingeing), night eating syndrome, etc. They review different features of ARFID to be mindful of as well as some treatment strategies that may be used. This is a good listen to prepare you for upcoming episodes that will discuss the treatments more in detail. Listen in and let us know if this helped you gain a better understanding of Dx in ED Tx!
Episode 10: Perfection vs. Obsession
In Episode 10, Jill and Meredith dive in a good discussion about anorexia nervosa (AN) and obsessive compulsive disorder (OCD). Whether you are a dietitian or a therapist, it is important to know comorbidities that can occur with eating disorders; OCD is a major one. AN behaviors and OCD behaviors often look very similar and can easily be confused. Jill and Meredith help clear up any misconceptions there may be about this by defining OCD and providing examples of OCD behaviors, discussing the similarities and differences in AN and OCD behaviors and treatment, and providing examples of features that would help distinguish OCD versus AN when it comes to excessive exercise, restriction, eating behaviors, and anxiety around food. Lastly, Jill and Meredith talk exposure response prevention (ERP), a treatment approach for each diagnosis. Do you know when to diagnosis AN versus OCD? Is it possible for a client to be diagnosed with both at the same? Or do they have to be diagnosed separately? Does the therapist or dietitian do ERP? What is the therapist's role in ERP. What about the dietitian? Are there differences in the ERP approach for each diagnosis? You'll know the answer to these questions by the end of the podcast.
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Discussed in this podcast:
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The starvation study (click here! to read it)
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Peace of Mind (non-profit organization whose mission is to help improve the quality of life of OCD sufferers): link to their website
Episode 11: The Trials of Termination
In Episode 11, Jill and Meredith discuss the process terminating a client. They compare how they handled terminating clients when when they were first starting out versus now, as more seasoned clinicians. They provide examples of reasons they have needed fired clients, both in the past and now. Do you fire a client if they require a higher level of care but refuse to go? Do you fire a client if they refuse to see a therapist, medical doctor, and/or dietitian, and will only continue to see you? They will review various options you have in different instances. Jill and Meredith end the podcast with discussing "following your gut." knowing your own limits as a clinician, scope of practice and ethical boundaries and requirements in your profession. Listen in to learn more on how to handle this difficult situation!
Episode 12: Meal Plan Mayhem
In Episode 12, Jill runs the show by discussing meal planning and the pivotal role it plays in eating disorder treatment. When struggling with an eating disorder, clients often become out of touch with their own biology. Jill talks about the dietitian's vital role in helping a client get back in touch with their biology and how meal planning in an important tool the dietitian uses to support a client return to normalized eating. She reviews various types of meal plans that will help dietitians in the field understand different approaches to meal planning that can be used with clients who have different needs. Meredith provides her perspective as a therapist on what a dietitian does and her understanding of various meal plans interventions she has seen. This podcast is a great listen for dietitians who may be newer to the field, or new to outpatient after time in higher level care, or even a more seasoned dietitian in need of a good review on the topic. This podcast is also great for therapist to understand more about the role the dietitian plays on the treatment team and the role the meal plan plays in treatment!
Episode 13: Resistance: The Attempt to Prevent Something by Action or Argument
In Episode 13, Jill and Meredith discuss resistance when working with clients struggling with eating disorders. They review the definition of resistance, the function and meaning of resistance, and review methods of dealing with it from both the dietitian's and the therapist's perspective. Do you know what resistance sounds like in a session? Resistance comes in many different forms and in this episode you will hear multiple examples to be able to better recognize when it. How do you handle resistance when it appears in the room? How to you help a client work through their ambivalence of wanting to stay in their eating disorder and work towards recovery? Sometimes it means taking off your "expert hat" and learning into the resistance with them. This episode will help you learn how embrace your client's resistance and work with it!
Episode 14: Your Dieting Daughter or Mother or Father..
Often when working with a client struggling with an eating disorder, their main support system is usually their parent, sibling, other family member, or spouse. What if their main support is also dieting? What do you do? In Episode 14, Jill and Meredith discuss dealing with dieting parents, spouses, family members, etc. Do you know how to handle this? Do you educate the parent on dieting or try to convince them to stop? What if a parent is refusing to keep certain exposure foods in the house due to their own beliefs or behaviors around food? Jill and Meredith discuss cases and examples that will give you some insight on how to handle this as a dietitian or a therapist.
Episode 16: V is for Vacation (No, wait! Actually Vegan or Vegetarian)
In this podcast, Meredith and Jill discuss working with clients that identify as vegan and vegetarian during recovery from their eating disorder. Jill defines the differences between vegetarian and vegan and her thoughts on this from a dietary and health standpoint. Meredith reviews the role of a therapist in helping a client identify their reasoning behind this decision and how it may affect their relationship with food as well as their relationships. What are some reasons for a client to not be vegan or vegetarian? What are some reasons it may be appropriate for others? Does eliminating an entire food group impact a client's likelihood to recover from an eating disorder? In episode 16 you will learn how you can handle this as both a dietitian or a therapist!
Episode 15: Recovery Red Flags with Clinicians; Calling in & Out
It is not uncommon for clinicians working in the field of eating disorders (dietitian or therapist) to have gone through an eating disorder themselves. Many who have struggled with any eating disorder want to work in the field to give back and help others struggling with eating disorders. At what point in the recovery process are they ready to be in the field? Is it a certain amount of time? 1 year or 5? What are the signs that an individual IS appropriate to be a clinician treating eating disorders? What are the signs they are NOT appropriate? In episode 15, Jill and Meredith provide some insight on this touchy topic with hopes of providing guidance and supervision to those entering the field.
Episode 17: Bariatric Surgery, Slicing and Dicing: Understanding Bariatric Surgery and Disordered Eating/Weight Control
In episode 17, Jill and Meredith discuss bariatric surgery and disordered eating. Jill reviews the basics of bariatric surgery and how she handles clients who are wanting bariatric surgery from a dietary perspective. Meredith discusses her approach as a therapist, including why she works closely with the dietitian and areas she focuses on in sessions. How do you approach eating disorder recovery after a client has already had bariatric surgery? For client's who are wanting the surgery, do you take them on as a client? If so, do you support them on this decision or do you try to convince them otherwise? Is it okay for them to have bariatric surgery? Why it is important to be open minded as a eating disorder clinician when it comes to bariatric surgery as well as other topics outside of your beliefs and your field? Episode 17 will answer these questions and so much more. Listen in and enjoy!
Episode 18: So Tell Me What You Want..... What Ya Really, Really Want?
It is not uncommon for clinicians to have an "ideal clients" that they enjoy or feel the most comfortable working with. This could be a specific age group, specific diagnosis, family dynamic, etc. As a new clinician, how soon should you narrow down what type of client you see? If you become too narrow too quick, you could potentially miss out skills set you may develop working with a wide variety of clients. If you a more seasoned clinician, what are some other reasons for seeing a wide variety of clients vs. exclusively your "ideal client?"Jill and Meredith share their own experiences as eating disorder clinicians and supervisors when it comes to narrowing down your practice to your ideal client.
Episode 19: Jumbo Shrimp and Intuitive Eating "Meal Plans"
In Episode 19, Jill and Meredith discuss intuitive eating in the eating disorder recovery process. Jill reviews the function of a meal plan for clients struggling with eating disorder behaviors, which was discussed in detail in episode 12. She discusses reasons intuitive eating is often not appropriate for clients in high level of care and what that transition away from a meal plan may look once they step-down to outpatient. Meredith discusses her role as a therapist in this process and points on common misconceptions clinicians may. What are the signs that a client may be or may not be ready for intuitive eating? How does the transition look from a structured meal plan to intuitive eating? What are some instances that a client may temporarily return to using a meal plan once they are an intuitive eater? In episode 19, Jill and Meredith discuss this very important topic!
Episode 20: "Supper"-vision: What is it? And What it's Not
In Episode 20, Jill and Meredith discuss supervision in the process of becoming a certified eating disorder specialist such as a Certified Eating Disorder Specialist (CEDS) or a Certified Eating Disorder Registered Dietitian (CEDRD). Meredith outlines supervision required for a therapist to become a LPC or a LCSW. Jill describes how this differs from becoming a Registered Dietitian (RD) and the reasoning for hiring ED dietitian "residents" in her private practice. Together, Jill and Meredith review the requirements to become a certified eating disorder specialist as of Fall 2019 through the International Association for Eating Disorders Professionals (iaedp) as well as why they find it useful to hold supervision together as a therapist and dietitian.
Episode 21: Compassion vs. Colluding
In episode 21, Meredith and Jill discuss the difference between compassion vs. colluding when working with a client struggling with an eating disorder. Compassion is used to help the us connect with the client and validate where they are at in their recovery. However, clinicians must continue to push and hold the client accountable to the recovery process. How does a clinician avoid aligning with the eating disorder? What are signs that we are colluding vs. being compassionate? What are reasoning clinicians will often collude with a client's eating disorder? Understanding how to give compassion rather than collusion is vital to being an effective clinician.
Episode 22: Client Case Conceptualization
In episode 22, Jill and Meredith discuss the importance of initial assessments with client and why properly conceptualizing your client is crucial for treatment planning, providing evidenced-based care, and building your confidence as a clinician. They discuss how case conceptualization differs as a therapist versus a dietitian. Do you know what questions to ask? What about observations of your client should you be aware of? Listen in as Jill and Meredith review this very important concept!
Episode 23: New York City?
This is a special episode where Jill and Meredith express gratitude to all of the amazing listeners of this podcast! They share a message from a listener who left a message which inspired them to take a pause to say THANK YOU for listening and keeping them motivated to keep the podcast going. Jill and Meredith share details about their upcoming presentation at Eating Recovery Foundation Conference on October 11, 2019. Come out and see them!
Episode 24: Forming, Storming, and Norming
In Episode 24, Jill and Meredith discuss group therapy. This episode covers so much information about what to expect when forming groups such as how people interact in groups, what clients can get out of groups, how groups differ from individual sessions, and how they can be helpful or harmful. Jill and Meredith also review different groups types (support, process, educational, open vs. closed) and how their groups have differed when they have co-led groups vs. leading them alone. How do you get people into groups? What are different ways to advertise groups? How many people should be in a group? What are ideal times to have groups? How long do groups typically last? What are some expectations to have for an ED group? Listen in to episode 24 and learn so much useful information about group therapy!
Episode 25: Fat vs Fat
In this episode, Jill and Meredith discuss why our clients want to know the ins and outs of nutrition and how to maximize their health, despite this fixation being the very thing keeping them unhealthy. Clients often come in wanting help sticking to their ‘perfect’ self-prescribed diet plan, not realizing that this strict plan is the very reason for their binges. Meredith explains why it’s important to dig deeper into your client’s reported foods, especially if they’re not seeing a dietitian, and how this can lead to further reporting of behaviors. Jill explains how nutrition education and guidelines can be presented to encourage food freedom, when at one point the same nutrition guidelines were construed into an eating disorder.
Episode 26: Stay in Yo Lane
With scope of practice boundaries, dietitians and therapists at times "cross over" to the other's area of expertise. We call this boundary a "white picket" fence. Dietitians may talk about skill work to enhance what the therapist reviews in session and a therapist may gently talk about meal planning concepts. Meredith and Jill strongly believe that to be a well rounded clinician one must "learn outside" their typical practice area.
Episode 27: Proactive vs Reactive
We often go into the field because of a strong desire to help others- but when does this desire get in the way of ethical care? Boundaries- holding ourselves accountable for our clients and ourselves. We discuss how to be flexible with boundaries so we can accommodate clients while maintaining our needs. As our needs shift, so do our boundaries, and therefore our ability to accommodate clients! Maybe the value of adding more clients is less than the value of having a day to yourself. Maybe our care will be more effective if we’re well rested. As technology keeps us ever connected, we explore how we can separate our personal lives from our clients’ care. What about the dreaded moment when you bump into a client out of your office? With the holidays approaching, gift giving comes with it. We navigate these sometimes hard conversations with proactivity- not reactivity.
Episode 28: Faith vs Fasting
Does religion ever come up in your sessions? How can you discuss it ethically, especially if their recovery is woven into their religion? Maintaining your faith separately from your client’s session is oh so important. Training and certification are available for those who want to specialize in faith-centric treatments. Meredith and Jill discuss using religion to advance treatment when the client is wanting fait based practice. CBT and gratitude through religion can help repair relationships with food by reframing thoughts. Learning about religions is important to better know the client and their value system. Self disclosure around religion can open new boundaries that need to be set. Faith based fasting can often be influenced by an eating disorder, and working through this challenge while being mindful of their religious values is necessary to respect the client and continue their care.
Episode 29: Happy Holidays!
Holidays can bring stress and busy schedules, family and food. With that, eating disorder thoughts and behaviors often increase. Meredith and Jill discuss how these stressful events be utilized as tools to encourage learning, grow in recovery, and challenge food rules appropriately. It is important to give clients skills to navigate family dynamics and diet culture over holiday meals. Clients often let appointment frequency decrease, which can promote challenges in skill enhancement. Holidays can also bring up feelings of grief for emotional events from the year and can be overwhelming for perfectionist clients who try to do it all. It’s important to stress that clients need to prioritize self care- including attending appointments and setting boundaries with family.
Episode 30: The Tortoise and the Hare (the true story never told)
Impulsive vs controlled personalities can influence a person’s experience with an eating disorder. Perceived impulsiveness can actually be malnourished-induced binges. Comorbidities can also influence how a person's impulse vs control appears in the session. DBT is commonly used for those who need help with impulse control, and RO-DBT is used for those that are overcontrolled. Meredith touches on the different skills taught in each therapy. Both involve coaching and frequent sessions to build strength in the skills learned. On the nutrition side, impulsivity is countered with structured meal plans and planning ahead when emotions are low. For overcontrol, structured meal plans are also used to challenge food rules and portioning. Visual guides, such as the plate method or eyeball measurements, are often used to encourage flexibility with food. Collaboration is essential to merging the two fields so that clients can fully understand what is asked of them and how they can apply it to recovery.
Episode 31: Ethical Dilemmas
Alright y’all, this one’s important. Today we talk about ETHICS! Boundaries are so important to hold. As clients express their respect and trust, it can be easy to be pulled into an unethical relationship. How do we handle a client’s advances? We can express gratitude for the compliment, and remind them that this can feel like a personal relationship, but it is professional and we are unable to spend time with them outside of session. Maybe they have a skillset (carpenter, lawyer) that you need, but these are still considered dual relationships. Sometimes our clients might know our children from school- we can bring up that we may be seen at their school and discuss how we can keep our clients comfortable with this connection. Supervision needs to be kept as just that- supervision! Don’t ask questions or talk about clients on social media. We explore how to practice within our scope and why it’s important to stay in our lane. Quick note taking and using evidence based practice are often looked over when thinking about ethical guidelines.
Episode 32: It's not just about "control".....
Meredith and Jill talk about control- and why it’s a blanket statement for eating disorders, even though it’s used by many. “Oh their eating disorder is just about control.” Well, of course it is! But, what’s underneath that a client is attempting to control? It’s really about managing their emotions after trauma, finding order in the disorderly, feeling special, lack of trust, etc. So when you’re collaborating with a clinician and you say your client developed their ED to gain control, that term includes so many possibilities- get specific! Or if you are not sure, seek supervision or work on learning more about the complexities of eating disorders treatment.
Episode 33: Working with a client who holds your degree
Meredith and Jill explore what it might be like working with an client that shares the same field you do. Working with someone in your field can feel intimidating, a sense of pressure to "say the right thing" or even feelings of being judged for not being a "good therapist or dietitian." We also explore working in the field of eating disorders and how going to therapy yourself can be helpful as a form of self-care and/or for struggling with mental illness as a clinician.
Season 2
Season 2, Episode 1: Evelyn Tribole on implementing Intuitive Eating when working with a client struggling with an ED- Part 1
Evelyn Tribole has co-written an updated version of Intuitive Eating, available June 23rd, 2020.
Learn more about Intuitive Eating here.
Read more about Evelyn Tribole, MS, RDN, CEDRD-S here.
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How do you know your client is ready for intuitive eating when they have been in the throws on an eating disorder? Please welcome our first guest on our podcast Ms. Evelyn Tribole, registered dietitian who co-authored THE book Intuitive Eating!
In this episode, Evelyn discusses the importance of supervision for clinicians when providing guidance on the concepts of intuitive eating process. Evelyn describes IE as an important goal that the client knows they can “recover to.”
Questions she asks clinicians she supervises AS WELL as clients she works with: “Why do you have the belief you are ready for intuitive eating? And what informs you of this belief?
Supervision is imperative as knowing how to provide guidance to your client goes well beyond any intellectual knowledge that you have. Many have read her book, but supervision provides guidance around the experience of supporting your clients during this process.
Intuitive Eating has a few very small studies around the implementation specifically with eating disorders. Many more studies need to be performed! So where do you start?
Questions to ask your clients: “What are they capable of doing?” Can the client know and “listen” to their own body? Can they adequately respond to their body? Those in the throws of their eating disorder need a nutrition rehabilitation meal plan. BUT you can provide some insight into concepts of intuitive eating when they are on more structure. Questions you might ask your client to build intuitive eating awareness are “How does this food feel in your body?”, “How did it satisfy you?”, and “ What were you experiencing as you ate this food?”
Generally a client needs structure. Evelyn describes this as the body being ravaged by the eating disorder and they need a CAST first to stabilize their eating behaviors.
So what are the indicators your client may be more ready? What Evelyn describes as “Free Range Intuitive Eating?”. You will only know this when you have met the client where they are and have provided baby steps along the way. This requires a certain skill level of the clinician (which can be garnered through experience and the supervision process.)
Evelyn also discusses the Cognitive Somatic Distortions that come from eating disorders. When a client does not own their own truth, confusion ensues, fear develops and a complete mistrust of food sets in .
When intuitive eating is introduced too fast Meredith describes this as “drinking from a fire hose.” Baby steps are so important. A question Evelyn asks her clients is “Why do YOU want to recover?”
An important aspect of supervision and understanding how to implement in OP, RTC/PHP or IOP is understanding weight stigma, fat phobia, social justice and thin privilege. This is evident by “food addiction” concerns many clinicians continue to embrace. She describes this as a way of fear mongering. Evelyn strongly feels clinicians need to be well informed on the Health At Every Size concepts and examine your own biases or as Meredith discusses at “least be aware” and discuss in the supervision process. How can you effectively validated a client’s experiences when they can’t fit in an airplane seat for example.
Evelyn wishes clinicians understood that Intuitive Eating is about rational thought, instinct and understanding how emotions play a role in the eating process. The framework of IE is self care.
She feels many clinicians in the field know and understand the Intagram or version of Intuitive Eating and do not know that it actually has 120 studies and counting and is based on many constructs of human development and theories. She feels especially dietitians are not taught the unethical and poor effects of dieting in school or internships. Evelyn discusses that Intuitive Eating is not an opinion or a belief and finds that many clinicians make assumptions without being informed (reading studies, reading the book or supervision process).
In January, Evelyn is providing Intuitive Eating education that is more eating disorders informed (as not all professionals that learn Intuitive Eating desire to be in the eating disorders field). She feels with IE, clinicians need to be at least informed about EDs and HAES just as they would with trauma if working with ED clients.
SUPERVISION is NEEDED:
Supervision provides the canvas for the “art” of Intuitive Eating implementation in the eating disorders population. Learning about Intuitive Eating is imperative but through working with clients with eating disorders you begin to learn the nuances. The supervision process provides the confidence and appropriate implementation of skills when working with eating disorder clients.
Evelyn also strongly feels in order to work in the eating disorders field and appropriately provide guidance with Intuitive Eating, the clinician must heal their own unresolved issues with eating. You can “do harm” to the client as well as most only take a client “as far as the clinician has gone” in their own relationship with food.
The more the clinician is skilled at understanding their own body and how they feel, this can effectively inform us of the questions and generally inform the work that is provided in session with a client. When the clinician is able to effectively “see, hear and affirm ” a client this is a huge step in the recovery process. These skills can effectively be learned through the supervision process.
Evelyn does provide a small amount of supervision through her Intuitive Eating courses, however she strongly feels that if a clinician is going to work with eating disorders the clinician needs to have supervision and was happy to hear that this was required to become certified as an eating disorders specialist. This is a new concept for dietitians overall as continued supervision is not required to become fully licensed or registered.
Season 2, Episode 2: Evelyn Tribole on implementing Intuitive Eating when working with a client struggling with an ED- Part 2
Evelyn Tribole has co-written an updated version of Intuitive Eating, available June 23rd, 2020.
Learn more about Intuitive Eating here.
Read more about Evelyn Tribole, MS, RDN, CEDRD-S here.
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In Part two with our guest Evelyn Tribole, Jill and Meredith discuss a therapist’s role in intuitive eating and interoceptive awareness, as well as how Intuitive eating can be used throughout treatment, adn how it can merge with a meal plan. It can remind therapists of trauma related practices in terms of body responses. Overlap in treatment is expected and actually a good thing! Congruence of practice is so important. Communication is key with treatment team members to have consistency in messages and correlation of care. It’s important to have a variety of team members to refer to that are skilled in their scope with Intuitive Eating. When treating eating disorders, “If in doubt, refer out” and “Know your scope” are Evelyn’s mantras!
Intuitive eating is often taught too soon in recovery from an eating disorder- before the client has made peace with food and connected to their body cues. So, should residential treatment centers recommend intuitive eating for their clients or discharge them on intuitive eating? Asking “How is your body ready for Intuitive Eating” and listening for concrete answers is essential in knowing their readiness. Wishy washy answers tell the clinician that they are not recognizing body cues and responding to their needs.
“We’re looking for nutrition rehabilitation- that’s a fact” Evelyn says as the goal form a nutrition standpoint at the residential level. Feeding your body and working towards recovery is the goal- even if you’re not ready to be an intuitive eater yet. Nourishment is self care! Intuitive eating practices can be implemented even on meal plans and if people need to distract themselves from body cues to get nourishment. A healthy mind, eating enough food, and flexibility are foundations for intuitive eating and must be instilled in the client before intuitive eating. Hunger and fullness can be swayed by an eating disorder. They might not be ready to be an intuitive eater, but you can talk about body trust and body kindness. Clients might be desperate to be intuitive eaters, and reject the structure of a meal plan. Discharging from an eating disorder recovery program is often when a person is most vulnerable and therefore needs a structured meal plan according to Evelyn.
Intuitive eating can be implemented one day at a time. Clients can learn that disordered thoughts may come up, and they can choose to nourish their body at the same time. Waiting until a client is ready for this stage to introduce intuitive eating will reduce some trauma around behaviors and give them confidence that they can recover and be free of behaviors. If it’s introduced too soon and have behaviors without the structure of a meal plan, they may feel like they’ve failed and get discouraged to continue the recovery process!
Intuitive eating gives clients something to recover to- a hope that with recovery they will learn to know their body and respect its needs. It can be a point of ‘failure’ if introduced too early and clients may lose hope. It can be talked about in residential areas as a goal and reason to follow a meal plan, as clients will be able to come off of a meal plan as they gain body cues and trust.
Season 2, Episode 3: Punk Rock vs Classical Music
In this episode Jill and Meredith discuss how to work with a clinician who has a different practice style than you. When clients come to you as a referral, they may expect the same style as their first clinician. Our intuition and judgement might tell us that our client needs a different approach, but our own discomfort may prevent us from following it. Sometimes we get feedback from supervisors or other collaborators that our style might not be working well with the client. When we refer, we want our clients to have a clinician that meets their needs,which includes considering the style or approach of the clinician.
Season 2, Episode 4: Meal Plan Anyone?
“Don't dietitians just make meal plans?” is like saying “Don’t therapists just give advice?”. It’s important that therapists be able to convey the essential role a dietitian plays in eating disorder recovery. You can explain that therapy is more effective when the client is not malnourished, the food piece is well educated and discussed, and eating patterns are regulated. Dietitians can aid in the recovery process by asking questions about their food intake, social aspects of food, medical history, body cues, eating patterns, where they eat, weight history, bowel habits, psychiatric history, and so much more! We also can search through the fluff of changing their eating patterns right before seeing a dietitian. We collaborate with the therapist to get a more thorough background of how their disordered eating affects their life. The therapeutic alliance is important in building rapport with the client just as this is important for a therapist’s relationship with the client. Sitting with the client when they’re not ready for change- not just expecting them to follow a meal plan immediately. This is why our services are called medical nutrition therapy, although we do provide nutrition education and guidance.
Season 2, Episode 5: Meredith, I need some advice!
In this episode, Jill and Meredith discuss the role of a therapist in eating disorder recovery. Therapy is not advice giving, friendship, conversation, or venting. It is based on well-studied theories and evidence based practices. Therapists will have one or several theoretical orientations that influence how they present in the therapeutic environment. Therapy encourages you to gain values, get introspection, and build confidence to make your own decision. “This is a process, not an event” as Jill says. Many clients expect to have a few sessions but may not expect treatment to be ongoing for more than a year. Sometimes clients get antsy to make big changes, and want to have immediate relief from symptoms. This can be handled by encouraging small direct steps between sessions until clients get the hang of the therapeutic process. Therapists help them to gain insight into their eating habits specifically, even if they have already had years of therapy to address trauma/anxiety/depression. The eating disorder may have been active and a uninformed therapist never screened, or thought through the lens of diet culture that restriction was an appropriate coping skill and saw dieting and self care. If setting the boundary that therapy is not advice feels uncomfortable, seek supervision!
Season 2, Episode 6: A Wrinkle in Time
In this episode, Jill and Meredith discuss what clients might experience when changing levels of care. Clients might start their treatment in residential and not yet accept the severity of their eating disorder. One purpose of a higher level of care is to move through ambivalence in a way that keeps them stable and safer than they would be at a lower level of care, even if they aren’t yet ready to completely face the struggle. In outpatient, Meredith describes work as “slow and steady” and “one step forward, three steps back”. Clinicians who start off working in higher level of care and then move to outpatient may experience slower client progress and feel ambivalence from the client. It’s important to meet clients where they are to avoid pushing clients away or focusing on setbacks rather than progress. In outpatient, a clinician should look at progress over a six month period rather than two weeks. When stepping down, clients will ideally have a discharge plan, relapse prevention plan, and be in contact with their outpatient clinicians before discharging. Continued support and communication with the client is important to solidify behavior change and continue to restore nutrition, as well as setting treatment expectations. Higher level of care can offer patients (and clinicians!) a more social environment to work and practice confrontation skills and validation from others.
Season 2, Episode 7: Diagnosing Dilemmas
From all the options a client might have for being diagnosed, how can you differentiate what a clients true diagnosis is? Diagnosis isn’t a label, it’s a key that can unlock treatment options. The DSM can have nuances that make diagnosing confusing. In anorexia nervosa, a diagnostic criteria is low weight. However, some clients are not considered as having a low weight, but show all symptoms of anorexia nervosa. In these cases, they will be diagnosed with OSFED- atypical anorexia. With children and teens, we use growth charts to determine usual body weight. If they are below their usual body weight, they will be considered to have anorexia nervosa. Clients who are in larger bodies have higher caloric needs, and many diets are at a low enough calorie threshold to spark anorexia nervosa. They may not be in a thin body to where all medical professionals recognize them as experiencing AN or think they’re ‘sick enough” to receive referrals to eating disorder treatment. Fixation on food, hypotension, and life disturbances are prevalent enough to warrant a diagnosis- even if the person does not appear malnourished or underweight. When determining higher level of care options, ask treatment centers about weighing procedures, mixed mileues, and weight biases of clinicians. Site visits are important to determine appropriateness of fit to the client’s individual needs, including having furniture that can accomodate the clients’ body comfortably without making them feel ostracized.
Season 2, Episode 8: Are You Still in Diapers?
Are you still in diapers? Meaning- are you a new clinician? New clinicians are often asked questions like their age and experience. These can be handled professionally and can be insight into the family’s beliefs and thoughts about treatment. It can be a sign of transference, ability to relate, and capability. When clients ask us about more personal topics, we can experience countertransference and pass judgement onto client for their boldness in asking these questions. As we gain experience as clinicians, we also gain confidence. The Dunning-Krueger effect explains the phenomenon where we think we know, then realize we don’t know, then finally realize we do actually know what we are doing. This is common in new clinicians who are learning about the vast information about eating disorders. As we discover more information exists, we begin to feel less competent until we dive into the information and study it thoroughly. It’s important to focus on the ‘why’ behind a client asks a question. Self disclosure after a question is asked is not always appropriate, and it may need to be redirected. Answering questions could build a friendship instead of a therapeutic alliance. Be curious about when and how you self disclose, and what it might mean about your own insecurities in the room. How can we best respond to these questions? Shutting down the question can harm rapport building. Meredith explains self disclosure as “We are humans before we are therapists or we are dietitians”. The therapeutic alliance is the biggest agent of change. Responding in a way that is humorous, engaging, and establishes good rapport can help a client feel heard, even if you do not want to answer the question directly. Dress for success is your motto if you notice patterns of initial meetings with clients not going great. Encouraging curiosity is helpful throughout the recovery process, including answering unwanted or inappropriate questions or comments.
Season 2, Episode 9: Are If I knew then what I know now with Amanda Holben, RDN
Please welcome our guest, Amanda Holben, RDN! Amanda is here to tell us what she wishes she had done differently at the beginning of her practice. She began her career at Remuda Ranch for several years and UT Austin as well as private practice in Austin, and eventually moved to Houston and opened her outpatient private practice. As she has a wealth of experience, Jill and Meredith ask her- what would you have done differently when you began practicing? Amanda wishes she had taken an abnormal psychology class to learn the lingo and have an in-depth view of mental health concerns. She also wishes she was more open to learning from clients and not feeling like she has to know the answers to everything. Jill explains that each client is an individual and it’s important to see their unique eating disorder traits, and Meredith explains that a messier recovery process is better than temporarily abstaining from behaviors. Reflecting on yourself after a session creates growth in the clinician and helps you face the clinician blocks head on. Tuning into a client’s non-verbal cues can help build trust and make the client feel heard; it’s important not to ignore non-verbal cues and to bring them into the room.
Season 2, Episode 10: Mommy and Me with Amanda Holben, RDN
In this episode, Jill, Meredith interview Amanda Holben, RDN about the transition from a hectic professional career to focusing on parenthood. Amanda feels that choosing to pause a career to focus on motherhood is a huge decision, but not the right decision for everyone. Amanda had a successful private practice, and found herself in the position where she could stop working and stay home with her daughter for as long as she can. Amanda feels that she can work at any time, but her daughter will only be a child for a set time. It also has allowed her to reconnect with herself and who she is outside of work. It also gives her a different perspective of the world outside of the anti-diet bubble. Giving herself a break from work allows Amanda to recover from burnout and return rejuvenated and restored. Perspective can shift once you’ve stepped away, and can see that clients who want to get better will get better.
Season 2, Episode 11: Burnout Anyone?
In this episode, Meredith and Jill discuss causes of burnout and how to recover from it, and even how to prevent it. What is burnout? Jill discusses that balancing motherhood, high clients levels each day, and multiple job responsibilities contribute to her burnout. Meredith discusses how life stressors impact stress levels about client load. Learning your own boundaries around how many clients to see per day and week, lunch breaks, and working location is a good start. Some people like low client loads per day, but work several days per week. Others prefer to have whole days off to balance work and life. Check in with yourself about how you’re handling a client load. While shifting boundaries around work, it can bring up fears that clinicians will no longer refer or business will slow. Moving towards values- be it time or family or rest- can improve overall balance and enjoyment of work. Knowing your strengths and using them can alleviate stress. Balancing more strenuous clients with less clinically impactful clients or setting boundaries around age or therapies used can preserve your strengths and make sure they are used to their full advantage. “Know yourself and now what your needs are” is the mantra to repeat if you’re a new clinician figuring out boundaries around work and life balance. Building a therapeutic relationship is important, and can be difficult if you take on too many new clients too quickly. Supervision and training can reduce burnout by validating the experience and finding solutions to problems a clinician is running into. Sometimes our feelings outside of session can bleed over into session, and therapy can be useful to work through big feelings outside of clients so it does not impact sessions. Be congruent with your recommendations and seek therapy if you’re struggling with burnout!
Season 2, Episode 12: Jill and her terrible, horrible, no good, very bad, day.
In this episode, Jill tells a story. After spending some vacation time in Colorado, Jill went to Virginia for a conference- where she ended up getting some weird ear symptoms with distorted hearing. After a history and physical, the doctor had a few things to say to Jill. Even though she went in with earache, he decided to tell Jill that she needs to eat healthier because of her risk of heart disease in her family. Of course, Jill was shocked. He even said that her vitals looked great, but still wanted her to eat healthier- even though he didn’t know what profession Jill was in. “I am so sorry, I didn’t know what your degree was” Jill recalls him saying.The majority of the appointment was spent talking about her weight, even though she was in a lot of discomfort with her ear. After the appointment, the doctor came running out to Jill’s car to apologize. It was a very inappropriate use of time- and a quick review of what she ‘should’ be eating is not an effective nutrition intervention. Jill walked away from it with deeper empathy for her clients who experience weight stigma more frequently. She chose not to interrupt him to fully experience what her clients might go through. The Health At Every Size movement can often be misrepresented and misinterpreted. Some think it’s about preventing health and allowing people to live unhealthy lives. It’s really about addressing people as overall individuals, not making assumptions about their health based on their weight. To educate others about HAES, it’s ok to give subtle education, you don’t need to be as dogmatic as you see on Instagram. Being open to discussion is helpful as it encourages a space to feel validated which is more likely to result in a changed opinion.
Season 2, Episode 13: Love, Adele
In this episode, Jill and Meredith discuss their love of Emotion Focused Family Therapy developed by Adele LaFrance. When they first were introduced to EFFT, they realized that validation is the key to family involvement in treatment. It enhances the work we do and bridges gaps between resistance and movement. Meredith feels like she engages best in presentations when presenters EFFT does not replace any therapy, and it encourages collaboration between many treatment modalities. It uses scripts to alleviate pressure if you aren’t sure what to say. The last part of the training is the best- doing your own work! As a dietitian, it helps Jill see how important the family is and why they need to be a part of treatment. Jill feels she can use the skills just as much as a therapist, especially in Family Based Treatment. EFFT is open for every clinician- not just therapists. Unifying the treatment team including doctors, nurses, all types of therapists, dietitians, parents, your neighbor- everyone! “You can be a very effective person in someone’s life” using skills from EFFT.
Season 2, Episode 14: Part 1: It's OK to Take a Risk with Kari Anderson, DBH, LPC, CED-S
In this episode, Jill and Meredith invite guest Kari Anderson, DBH, LPC, CED-S. Kari specializes in binge eating disorder and has experience in eating disorder treatment centers such as Green Mountain at Fox Run (now closed), Remuda Ranch, and the Rader Institute. She is a co-author of Eat What You Love, Love What You Eat and has a second book called Food, Body, and Love coming out in late 2020.
She reflects on her beginning in ED work when she used an addiction model and labeled herself a DBT-therapist. She gets excited from linking modalities together and correlating different therapies; and notices new clinicians get into a niche and don’t look into different modalities. She notes that modalities seem to come around in trends, like fashion. Kerri encourages her supervisees to take risks in their work with clients. She encourages them to experiment with modalities and find what works best for the client. She also finds just going back to basics and validating a client and coming into the room as a human can be really effective. Jill discusses how dietitians should be well versed on therapeutic interventions and modalities to support the therapist and incorporate therapy goals into sessions. Dietitians use traditional ’therapy’ techniques to accomplish the goals of nutrition therapy, without processing or doing therapy work. Similar to what we ask clients to do, we should expect ourselves to take risks and learn and grow from them. Risks are like exposures- you try it and pivot if it’s not successful. “If it works, that’s what it’s all about... it’s really about doing whatever works so people can have freedom again” Kari summarizes.
Season 2, Episode 15: Part 2: Holding Space for Clients Who Desire Weight Loss with Kari Anderson, DBH, LPC, CED-S
In this episode, Jill and Meredith are happy to have to discuss the desire for weight loss in recovery from binge eating and compulsive overeating. Just as we don’t want to tell our clients that they need to lose weight, we don’t want to shut down a client that desires weight loss, by telling them that losing weight is unacceptable. It is about finding a value structure to improve health, instead of relying on external factors. Often, clients are not ready to hear that weight loss is not feasible long term. Jill allows clients to explain why they want weight loss, and opens space to hear their ideas about a HAES approach. Often, telling a client that you will not help them lose weight leads to a feeling of failure and judgement for wanting to lose weight. Some clients may start off with a dietitian, unaware that they have an eating disorder. As we teach our clients how to manage disordered eating, they begin to organically leave dieting ideals and weight loss goals in the past. “Pushing our agenda is placing our values on our clients”- meeting our client where they are at its core. Taking off our expert hat and asking permission to educate makes a clinician seasoned enough to allow space for a client to talk. Jill finds that clients will use their own voice to talk themselves out of weight stigma and fight for their needs. “If we’re teaching the right things, we don’t need to set it up in the beginning”. Advocacy and therapy are two different things. While we want our clients to join us in fighting against weight stigma, it is not our job to force them into our beliefs.
Season 2, Episode 16: Role Playing: Bargaining & Non-Negotiables
In this episode, Meredith and Jill do something highly requested- role playing with a parent that wants to negotiate their child’s recovery weight. This is a common scenario across all types of eating disorders, and the role of the therapist and dietitian may look different.
When the ‘parent’ (Jill) brings up how frustrated she is with the dietitian and her daughter's fears about going back to her previous weight, the therapist (Meredith) starts first by validating using the EFFT emotion coaching model! The therapist then asks the client to elaborate, and asks how she feels seeing her daughter so distressed. The client is then able to get to the root- feeling like a failure for not supporting her daughter in the ways she needs and wanting to protect the daughter. The therapist then asks the client to reflect on how their child might view this problem later in life, and what her child needs to get there. “What I hear is that you want to protect her, and you want to give her comfort. And I wonder if there’s a way you can do that without agreeing with the eating disorder.” They then strategize ways to support the daughter and give mom a feeling of protecting her child without colluding with the eating disorder at the same time.
Next, Jill is the dietitian and Meredith is the client’s parent.
The parents want to remove the supplements from the client’s meal plan. Jill asks her to elaborate, and the parent explains that the supplements cause lots of friction and the client often becomes upset and will fight and throw things when given a supplement. Of course- Jill validates! JIll then explains medical markers and how it relates to weight and nutrition status. She also educated on the anger the client is feeling and how it comes out with supplement. As weight is restored, behaviors decrease and she will be able to process anxiety and frustration better. After educating, Jill always checks in with what comes up for a client/parent. The parent is able to explain that they are exhausted trying to get their child to eat all the time- and, you guessed it, the dietitian validated again!
The therapist wants the parents to feel heard and that it’s ok to feel these things. The dietitian needs to validate as well, though they don’t go as deep as the therapist. Education is an important part of a dietitians job, but it’s often unheard if we don’t show that we understand the parent’s perspective.
Season 2, Episode 17: Pancakes: How is THIS Gentle Nutrition?
In this episode, JIll and Meredith discuss the intricacies of gentle nutrition in the context of health conditions such as heart disease, diabetes, abnormal blood labs, etc. How do we address this if a client is also in the throws of an eating disorder? Meredith validates the confusion and frustration that can come with trying to heal from an eating disorder and also practice gentle nutrition. In Intuitive Eating, gentle nutrition is the last principle to allow people to heal from diet culture before embracing nutrition for health, but it does not always need to be learned in a separate principle one at a time. Often, clients are stuck in the binge-restrict cycle which causes overeating on foods that may impact their health. If you work on nutrition first, clients are so black and white with their eating disorder that they will hear that some foods are healthy and some foods are not. By approaching the eating disorder, you reduce shame that prevents clients from getting better. Medications are available that can help clients manage their particular condition while they build a solid foundation around food, even if they are resistant to going on another medication. Eating disorders can often be sparked by being told to go on a diet, even if a doctor is the one advising it. Timing and readiness are key. If the person embarks on gentle nutrition too soon, they will perceive it as another diet and it will build anxiety about their health, instead of elevating their nutrition in a gentle place.
Season 2, Episode 18: Part 1: Helping Without Harming with Robyn Goldberg, RDN, CEDRD-S
In this episode, Jill and Meredith bring Robyn Goldberg, RDN, CEDRD-S, and works with people with eating disorders including infertility and is an advocate for HAES. Robyn has a new book, The Eating Disorder Trap, which can start a dialogue on eating disorders for families and clinicians who may not have background knowledge in EDs. Robyn explains that we can’t always choose our team members, and educating a non-ED informed clinicians can teach them to help without harming. Often, schooling and internships do not provide thorough education on eating disorders, and clinicians misbelief that treating an underlying issue will cure the eating disorder. Communication style is important when educating other clinicians, as we educate we don’t want to shame for not having a solid education in EDs or blame the clinician for not picking up on the eating disorder. They may also not know how to coordinate care as part of the treatment team, and be confused as to why the dietitian keeps calling them. Introducing them to supervision and books are a good way to call them in instead of calling them out. Reaching out for supervision is how “we continue to evolve and flourish and grow versus remaining stuck, stale, and stagnant” as Robyn says.
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Robyn's new book The Eating Disorder Trap: a Guide for Clinicians and Loved Ones can be purchased here.
Season 2, Episode 19: I'm "Your 411" with Robyn Goldberg, RDN, CEDRD-S
In part 2 of the series with Robyn Goldberg, RDN, CEDRD-S, Jill and Meredith discuss how to advocate for our field and educate client’s loved ones about eating disorders. Robyn starts by explaining what ‘normal’ eating is, especially when their loved ones may be immersed in diet culture. The goal is to help a parent support their child- not change their beliefs around food.
Jill provides psychoeducation about helpful and supportive statements such as not commenting on food or body and instead validating the difficulty. Often, doctors perpetuate shame and misbelief around weight. Reeducating about the fable that you have to be underweight and sick in order to have an eating disorder. Having a medical background, especially as a dietitian, can provide some common ground with the doctor to help educate them on the labs we need and why.
Advocacy can build confidence and help gather resources for others. Robyn uses “pain statements”- something that will catch the attention of doctors/dentists/OB-GYNs that will make them think to refer patients to a dietitian and make sure they remember that the patient needs more than a 2 minute nutrition education segment in their general check up to see real change in health.
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Robyn's new book The Eating Disorder Trap: a Guide for Clinicians and Loved Ones can be purchased here.
Season 2, Episode 20:Therapy in the Digital Age (or is it Ice Age?)
In this episode, Meredith and Jill discuss using telehealth during the COVID-19 pandemic. Meredith finds the convenience and ease of telehealth to fit well in her clients’ lives. Meredith finds it easier to keep time boundaries, as it reduces doorknob conversations and drawn out goodbyes that sometimes occur when a client is in the office. From a clinical perspective, clients are able to see their usual therapist even if they live farther away. Clinicians can also see them in their home environment, where a client may let their guard down a little bit more. Sometimes clinicians can see the client interacting with children or family members. Jill points out how some clients feel they can multi-task, which indicates that they may not ever stop and ficus one one thing, which can also come out in menu planning and eating meals for themselves. One benefit is that you can save on rent if doing telehealth, and save drive time to spend energy on other things.
Some cons are that insurances often don’t cover telehealth, using an EMR that clients can upload their documents to, not feeling as connected, and not getting to be around coworkers that share a passion for EDs. Meredith’s only con is that she doesn’t do EMDR virtually, but other than that she’s living the dream! What we model by using virtual sessions, is going with the flow.
For virtual groups, it’s important to set boundaries and make expectations clear with privacy and attention to the group. For dietitians, sometimes parents or close friends can weigh the client, or doctors if needed. Flexibility around weight is needed, and sometimes having a client weigh themself can bring up the opportunity to challenge the ED voice. Reviewing malpractice insurance, licensure, HIPAA and telehealth laws are important during the transition to telehealth.
Season 2, Episode 21: Part 1: Therapy Is for Teaching, too!
This is a two part series on education in session. In this episode, JIll and Meredith discuss their role in educating clients. Dietitians key role is educating on common misbeliefs about food and challenging thoughts around food. As clinicians become more skilled, we tend to focus on deeper processing and asking the strategic questions- and we can forget the power of psychoeducation. Jill used to have an education checklist of all the things she would teach about in a session.
In a therapist’s session, how can we balance education, validation, and processing? Usually the first few sessions are filled with psychoeducation, so the client has a good foundation to build on. CBT & DBT are structured and involve lots of worksheets and education. It's important to know WHY we do psychoeducation- is it coming from a place of avoidance or feeling resistance and like we need to “tell them” something, or is it from a genuine clinical intervention? Listen on to Part 2 as Jill discusses the interventions often used in a dietitian’s session. Meredith and Jill will discuss in more depth the function of providing education in a session.
Season 2, Episode 22: Part 2: Therapy Is for Teaching, too!
In part 2 of Therapy is for Teaching, too! Jill and Meredith discuss inappropriately using psychoeducation when a clinician might be having a feeling that interferes with the session. In EFFT, education can be a clinician block. Providers may educate out of fear for the client, avoidance at diving deeper, and many more. It’s important to recognize why you’re educating. Dietitians can tend to educate when they feel like recommendations aren’t being adhered to, when really the client has an emotional block. Reading the room and building rapport with a client are strong skills to evaluate before you jump into education. “Nobody cares what you know until they know that you care” is a mantra Meredith uses.
Jill uses a motivational interviewing skill of asking a client if they’d like to hear more about an education piece before she dives in. Even though Jill isn’t a therapist, she will go into emotions and deep validation before educating, so that the clients know that she fully understands and cares. Noticing the client’s cognitive distortions and asking to confirm is important to know exactly where to target the education and help them unlearn. Often, validating and not assuming is more effective than jumping into education, as it allows them an open space to ‘peel the onion’ and get to the problem that’s blocking a change.
Season 2, Episode 23: 14 Characteristics of Effective Clinicians
with Douglas Bunnell, PhD, FAED, CEDS-S
Welcome guest Douglas Bunnell, PhD, FAED, CEDS-S! Dr. Bunnel has 30 years of experience in the eating disorders field. He is a clinical psychologist in Westport, Connecticut and New York, New York and is a past board chair of NAED and an awarded recipient of their lifetime achievement award. He has managed IOP/PHP programs with both Monte Nido and The Renfrew Center. He is a co-editor of The Treatment of Eating Disorders- Bridging the Research-Practice Gap.
Dr. Bunnell has a successful presentation on 14 qualities of effective clinicians. He created this to develop a standard of how we work with eating disorders, and also accelerating the training of new clinicians. This field is expanding, but there’s not many opportunities for training and learning for the new clinicians entering the field. What makes a clinician effective is not how well you know the material, but how well you use it. Greater self awareness, constantly improving, not avoiding avoidance, not avoiding complexity, and thinking outside the box are among what Dr. Bunnell has characterized effective clinicians.
Clinicians can sometimes get stuck in their preferred form of treatment. “We have an ethical responsibility to provide patients and families what all the different options are” and explain our rationale. Every treatment doesn’t work for everyone- if you’re being honest about struggling, you are more meant for this field than those who believe that treatments will work without fail. In this field, not every client is going to recover quickly.
Dietitians come into this field lacking psychotherapeutic skills. It’s just not taught in our curriculum. Dietitians have to learn these skills on their own. Motivational Interviewing is a good place to start when learning to communicate treatment plans effectively. Often, new dietitians feel like they’re not doing enough or not educating thoroughly because clients don’t follow through with their recommendations. Learning the psychotherapeutic side of discussions can help dietitians tailor recommendation to their clients needs.
“Go there” and don’t avoid the problem; fears of treatment not working out can hinder effectiveness. We can model flexibility and shame resiliency by admitting to a mistake, if we do take a chance and make one. We can have human behaviors- we don’t have to be so worried about professionalism that we lose genuine human connection. Have awareness as to why you’re doing it, but “having permission to play as a therapist can be really liberating”. In RO-DBT, a rupture in the relationship is expected and part of the therapy. If we’re not pushing, we likely aren’t doing our job. Not colluding and not avoiding is a key aspect of eating disorder treatment.
A new clinician has much to learn. The goal is for each client to have a really good understanding of what their eating disorder is about. However, we have to pick our priorities as clinicians to be most effective. We will likely not get to the entire list of problems with every client. Team meetings to understand every one’s role and responsibilities helps find the client’s priorities. Especially in outpatient settings, it’s harder to collaborate consistently between everyone’s schedules.
Season 2, Episode 24: 14 "Deep Thoughts" about episode 23 with Meredith and Jill
In this episode, Meredith and Jill talk about their thoughts on Dr. Bunnell’s interview from the last episode. Meredith emphasises taking risks such as being vulnerable, using humor, and using self disclosure with a client. Most therapists are overcontrolled, and have anxiety that makes them care about clients- sometimes the anxiety is because we care about clients. For some clinicians, they want to keep therapy on the more serious side from their training or style. Jill points out that this can sometimes lead to lessened therapeutic rapport, as clinicians won’t call out their own mistakes for a client.
Having a willingness to avoid not avoiding is needed for a dietitian, as our clients are malnourished and not making sound decisions- leading to resistance. Use validation and normalization, but do not collude. If you’re not getting supervision it can be easy to take mistakes personally. Jill highlights Dr. Bunnell’s idea that if you believe every client interaction will go swimmingly, this is not the field for you. Meredith points out that she hasn’t always had the thickest skin, and it’s an opportunity for growth. She mentions clinician blocks and EFFT as tools to work through clinician avoidance and resistance.
Finding a supervisor that’s not like you can strengthen your weaknesses and identify areas to strengthen.
Season 2, Episode 25: What's weight got to do with it? with Ralph Carson, PhD, RDN, CEDRD
In this episode, Jill and Meredith invite guest Ralph Carson, PhD, RD, CEDRD, LD, and is a clinical nutritionist and exercise physiologist. Dr. Carson also provided slide notes for this podcast- please sign up for the newsletter to receive these! We discuss how we can bridge the gap in the medical field that misunderstands eating disorders and size diversity.
HAES Community vs Medical Community 1 min
In eating disorders, we treat body sizes and eating patterns of both extremes. In anorexia nervosa, they are often too malnourished to begin talk therapy. With binge eating, the focus should be on health and wellbeing- not weight. They should not judge the patient, but should invest in the patient’s needs and life.
Many feel that the medical community and eating disorder community are two sides in an opposing battle. However, Dr. Carson explains that they are really two sides of the same coin- we both want our clients to have healthful lives.
Is Obesity a disease? 11 min
In the medical field, we have applied the word “disease” to weight. Government health programs and insurance agencies have used ‘obesity’ to receive financial reimbursement and standards of care. Some professionals feel that the word obesity as a disease leads to less stigma, as it removes the blame around the weight gain from the person’s fault to a genetic/environmental cause. But what about health conditions? Many research papers list weight as a cause of diabetes, heart disease, joint issues, even dandruff. Can weight really cause all these ailments?
It’s not fat, it’s VAT 17 min
Dr. Carson explains that visceral adipose tissue (VAT)- is intra abdominal, meaning between the organs. The fat that’s subcutaneous (under the skin) is what client’s most want to lose, think “jiggly arms or thick thighs”- however, this is not linked to health conditions. Metabolic conditions are caused by the ‘disease triad’ of stress, VAT, and insulin resistance.
Cancer 20 min
For every 3 inches of waist size increase, cancer rates rise by 15%. A doctor may look at this and link size and cancer risk together, but Dr. Carson explains it’s more nuanced than that. The omentum is an organ that sits just below the abdominal muscles in the abdomen. Many think it is just a layer of fat, but it does have a purpose. It filters fluid, cell wate, viruses, etc from around the other organs. The omentum decides what will happen with our immunity such as white blood cells and the inflammatory response. It can also be a breeding ground for tumors, as cancer cells can metastasize off into fluid which gets deposited in the omentum.
Intra-Abdominal Fat and Ectopic Fat 22 min
Central body fat may be a factor in our behaviors. Loss of control of eating can increase with the hormone leptin. Ectopic fat is fat that surrounds organs- it has a purpose other than fuel storage. Fatty liver is often asymptomatic, and can turn into cancer. The liver helps with blood sugar control, so when it is not functioning it can lead to metabolic diseases. Pericardial fat (fat around the heart) can lead to calcification of the vessels. Perirenal fat is around the kidneys and can cause high blood pressure, diabetes, and kidney cancer. Peripancreatic fat can cause pancreatitis, pancreatic cancer, and diabetes. Intramuscular fat can cause sarcopenia. As people age, we get more fat from hormone changes. As people age, they can cause fat in bones and muscles which leads to weakness in strength and weaker bones.
Subcutaneous Fat 27 min
Many think this is aesthetics. It usually doesn't cause health consequences. Women especially need fat around their hips and thighs as it provides DHA which is essential for fetal development and nutrients in infant breast milk. If there is excess subq fat, there is a concern. Suq fat plays in hormone development- an excess can cause breast, ovarian, and prostate cancer. A depletion can cause infertility, fetal abnormalities (if pregnant), and hormone abnormalities.
Mechanical weight complications 29 min
From the perspective of the medical community, sleep apnea, stress incontinence, hyperventilation, GERD, stasis, joint pressure, limited mobility, surgical complications, cardiac remodelling, gallstones, and skin rashes/infections can all be a disturbance in functioning from the pressure that weight can physically put on the body.
From the eating disorder community, the concern is that medical providers will assess a person’s health based on the number on a scale. We have prejudice if we only base recommendation on weight. We cannot know if a person is actually experiencing one of these conditions without proof. It is shaming and disrespectful to make a recommendation without evidence.
Is Obesity a Disease? 35min
Weight alone does not determine health. If we label obesity a disease, we automatically make 78 million adults and 12 million children ‘sick’, because a disease is a sickness. But, many have no health conditions. It may be a risk factor, but it is not the cause of death. Dr. Carson argues that we should focus on being metabolically sound and reducing stigma around our bodies. Comprehensive assessments, not assumptions.
COVID-19 and Weight 45 min
We cannot confirm that weight causes a decrease in health. Scare tactics are unethical. We have to look at the pathophysiology. The virus travels in the air- from talking, breathing, laughing, not just coughing or sneezing. When we’re in closed spaces with others, we raise our chances of contracting it. It attaches to receptors, when the cells multiply with the virus. It then goes into our upper lobe of the lungs which fills with fluid and impairs the oxygen exchange. Our lungs have to work harder. This next phase is the hyper-inflammatory phase. It’s not the virus, but the body attacking the cells that causes death- called a cytokine storm. The visceral abdominal tissue puts out cytokines, which cause inflammation. We can add to the cytokine storm by having more visceral tissue. We are also mechanically compromised by the tissue around the diaphragm and ribs that causes reduced lung capacity. We can improve this by positioning a patient to lay belly side down to allow for more lung expansion. The muscles get fatigued, and the brain sends less signals to slow the muscles. This is when a ventilator is needed. The quality of the research is questionable, as the information is new and we are constantly getting more information that adjusts our understanding of the virus.
The Media 60 min
If you’ve followed the media, you’d know that Adele has had weight loss of about 100 pounds. The HAES community was supportive of her, and now some say she’s a “traitor” to body positivity. Others are saying she’s healthier now. Either way, we can’t judge her or her weight loss. Dr. Carson explains how her statements include sleep, stress, exercise, nutrition, and excludes deprivation; these are health behaviors Dr. Carson prescribes in his eating disorder treatments and have been proven to improve health regardless of weight. Donald Trump was recently criticized for being morbidly obese- again, Dr. Carson explains this is stigmatizing and places assumptions on all fat people, especially when it’s highly publicized.
Meredith appreciates that exploring multiple perspectives can keep us growing and models being in the gray. Jill explains how dietitians bridge the gap between research and supporting a client in their progress, especially in difference between types of fat, when educating clients on the physiology of their bodies.
Season 2, Episode 26: "Deep Thoughts" about Episode 25 with Meredith and Jill
In this episode, Jill and Meredith discuss last week's episode with guest Ralph Carson (I’ll add his credentials). Jill feels that Dr. Carson is able to beautifully link medical and counseling sides of nutrition. Meredith reflects that openness does not mean agreement- we can validate the feeling without approving of the behavior. Many practitioners feel defensive around a client expressing desires of weight loss, and think that they are allowing their client to lose weight intentionally. Meredith does not approve of intentional weight loss, AND shutting down a client’s expression of wanting weight loss leads to feelings of shame.
Dr. Carson shows how both sides of the argument are not willing to listen to each other and attempts to bring them together- which is what Meredith does. Jill points out that she has worked in the dieting field- and saw clients were coming back like a revolving door. Jill encourages willingness to hear the other side, and our intentions are about helping and not harming.
Dr. Carson opens the door for critical thinking by posing the question “what in a fat cell hurts you?” If we’re calling clinicians out and saying we’re doing harm without helping them understand why and leaving it open for discussion, what harm are we doing?
Season 2, Episode 27: Supporting Budding Adults and Their Parents
In this episode, Jill and Meredith discuss how to support young adults and their parents. Often, parents want to support their adult children, but are roads blocked by the child and sometimes the clinician. How can we support both, at the same time?
Meredith explains that many therapists will not schedule with the client if their parent reaches out. Meredith sees parents as allies and the healthiest brain in the room. She likes to work with both, as we can get a bigger picture of the client’s life. It also builds rapport with the entire family system. Meredith sets the boundary that she will not keep secrets from the client about what the therapist and parent discuss.
From Jill’s perspective, she finds that parents want to know about progress and to tell the dietitian what they see- like wrappers in the bedroom or refusal of meals. Jill establishes trust by asking the parents to help their child by being honest and cc-ing the client on emails and being open to discussing what happens in sessions with the client. She tries to get as much info from the client, as uses the parents to fill on gaps. She always brings up what the parents say with the client, as a way to talk about shame they may feel.
Parents are the best bet to help the client get better. Because of the oxytocin bond and closeness with the client, the parent can assist in meals and emotion coaching using the EFFT framework. You can work with parents without an ROI- and can still provide education and emotional coaching resources if the parent calls you asking for support without disclosing to the parent what the child is saying in their session
Meredith explains that parents are coming from a place of distress and fear, and we can validate these to help the parent support their child. Through the EFFT framework, parents have the most influence over their child through oxytocin bonding. We can use them to model emotion regulation which will in turn help the client regulate themself.
Season 2, Episode 28: [REQUEST] Food, Trauma and Stay'n in Yo Lane
In this episode, Jill and Meredith discuss how to work with clients when they have trauma surrounding food. How do we keep scope of practice and boundaries separate, especially when it intertwines with the client?
Meredith asks tons of questions about their experience with food. She will then collaborate with the dietitian to determine if there’s any malnourishment, and if exposure based therapy can be used. Determining food exposures and the situation of the exposure (when, where, with whom) is discussed between both the therapist and dietitian to determine what’s most appropriate and helpful.
In nutrition sessions with the dietitian, clients sometimes may bring up their traumatic experiences in session and the dietitian realizes they accidentally opened a can of worms. Meredith suggests dietitians learn how to guide clients through grounding skills. Dietitians can also ask the client what coping skills they’ve used with their therapists. Deep breathing, textures of pillows/couches, using the five senses are all examples of grounding techniques to use WITH the client- so they feel connected. Validation is necessary, and acknowledging their vulnerability. Even though dietitians are not doing trauma work, trauma will come up in our sessions. Taking EFFT classes, trauma classes, or supervision can be helpful in learning how to help a client cope.
Season 2, Episode 29: Including Parents and Caregivers in Eating Disorders Treatment with Becky Henry
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In this episode, Jill and Meredith invite guest Becky Henry to share her experience in advocating for families’ involvement in eating disorder treatment. Becky relates self care to the foundation of a house- you can get exhausted quickly while helping your child recover. Our ‘cup’ has to be full in order to pour care into your child. Self care can be simple- going to the dentist, listening to a 2 minute meditation, even spending an extra minute in the bathroom to breathe.
Parents may feel guilty when taking time for themselves- if your child is on the edge of a cliff, if we take just one hand off they may fall and die. The changing point for Becky was realizing she’d have a better life if she stayed in bed all day instead of living it. She realized she had to take time for herself in order to have energy to help her child flourish.
In a fear state, we may not recognise the best thing to do. When our amygdala is firing, we are not in our logical prefrontal cortex and making sound decisions. Through breathing exercises we can lower the stress response and make sound decisions for our families.
As clinicians, Meredith and Jill reflect on parents’ fear around their child being “overweight”. They know to take time and recognize that a parent is using their gut instinct and picking up that something is wrong. So much of parent behaviors are pathologized or blamed for causing the eating disorder. We have to be willing to listen and meet them where they are- it may take several weeks of warming up to it.
Becky reviews what’s been helpful from her perspective. Communication with the parents is vital- if they don’t know what’s going on, anxiety will make something up. Recognizing their role in the team, and that they are just as vital as everyone else provides empowerment. Validating their feelings and recognizing what they can do in another way for more empowerment.
Weight can be a distressing topic. Parents have been told that lower weights are healthier weights. Beginning to separate the child’s health from the child’s weight can take time and uncover shame and stigma that comes with weight gain.
[REPOST] Season 1, Episode 20: "Supper"vision: What is it and what it's not.
In Episode 20, Jill and Meredith discuss supervision in the process of becoming a certified eating disorder specialist such as a Certified Eating Disorder Specialist (CEDS) or a Certified Eating Disorder Registered Dietitian (CEDRD). Meredith outlines supervision required for a therapist to become a LPC or a LCSW. Jill describes how this differs from becoming a Registered Dietitian (RD) and the reasoning for hiring ED dietitian "residents" in her private practice. Together, Jill and Meredith review the requirements to become a certified eating disorder specialist as of Fall 2019 through the International Association for Eating Disorders Professionals (iaedp) as well as why they find it useful to hold supervision together as a therapist and dietitian.
Season 2, Episode 31: Part 1: “Trauma and eating disorders; the burger keeps the score.”
Jill asks Meredith, what is trauma?
Meredith gives many different definitions, but for her clients, she generally says trauma refers to upsetting memories or experiences in someone’s past that affects the eating disorder.
The other definitions she offers are from several different dictionaries, and the DSM5.
The DSM5 says the person was exposed to death, near death, serious injury, or sexual violence. Meredith thinks this definition is too narrow.
Meredith also considers that people who have “household dysfunction” (incarceration of family, alcohol abuse in family, drug use in family, etc) also experience a form of trauma.
Jill has heard about the idea of “big T” and “little t” trauma. Meredith explains that sometimes people use “big T” to describe obvious traumas like major car accidents, deaths, serious physical abuse, etc. but “little t” things can be a less obvious experience like being bullied as a child, etc. She also shares another interpretation… “Big T” is a trauma directly experienced, but “little t” is trauma observed happening to someone else. In either case, she stresses that we want to move away from a big T little t mentality because we don’t know how great the trauma response is to an event based on what the event is.
Meredith then relays an experience she had with a teen client in therapy to illustrate the point that it’s important to use your client’s language. The teen corrected Meredith with she was referring to the teen’s parents as Mom and Dad. The teen only calls her parents by their first names.
Jill asks Meredith, what kinds of trainings are out there that focus on trauma? Meredith says there are LOTS of trainings out there, and different therapy approaches work for different clients, but most important for trauma clients, TAKE YOUR TIME. She says that a little psycho-education around trauma could be very helpful for many in order to help them to help them through guilt they may have about a natural response to a traumatic event.
She says that EMDR is a recommended training, but it takes many months to go through. EMDR is more specifically suited to a client that comes in with specific images or memories associated with a traumatic event.
Meredith then briefly discusses “dual-action stimulation”, as used in EMDR, and prolonged exposure.
Jill, looking for an example of prolonged exposure, tells a personal story about almost being in a plane crash with Meredith, and then watching a Netflix series immediately afterward about other almost plane-crashes.
Meredith gives a more ED applicable Internal family systems (IFS) is another approach to trauma treatment that Meredith brings up, though she is not trained in it. She discusses that it is a positive approach that identifies parts of the person that are trying the help him/her manage his/her life.
A few other trauma approaches are briefly mentioned, but not explained.
Jill emphasizes that most of these methods should not be used without extensive training, but the two agree that dietitians may be able to incorporate the principles behind these approaches into their practice.
[REPOST] Season 1, Episode 4: Body Image, Diving Deep
Season 2, Episode 32: Part 2: “Trauma and eating disorders; the burger keeps the score.”
Jill and Meredith focus this episode on symptoms of trauma and when to refer out for someone who needs advanced treatment.
Jill asks, can you fully resolve a trauma issue with advanced treatment?
Meredith starts by saying that we should think about trauma responses as “fight, flight, or freeze”.
She explains, when we are triggered, it’s easy for our brains to go into fight or flight mode. We see this in clients when they storm out of session, become very rigid with people and food, etc.
However, the freeze response is the client who is really shut down. This client has very few facial expressions, they don’t feel present, and they have a very flat affect. They may describe themselves in session as looking into the room over their own shoulder, but not being involved. They may be telling you about something very terrible that happened to them, but they seem very indifferent about it, as if they are sharing their grocery list with you instead of a traumatic experience. Meredith says we want to get this client to a point where they are regulating their emotions, but not feeling numb.
Jill recognizes that a lot of diagnoses ED clients have can be characterized by “fight, flight, or freeze” and she asks Meredith to talk about some of these diagnoses.
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Some are bipolar and they present with these responses, but they need a good psychiatrist first.
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Some present with these responses because they are malnourished, but they need to see a good dietitian right away.
Jill emphasizes the importance of learning your individual client in order to properly identify what is wrong with them. Are they struggling with trauma, or is it something else?
Meredith replies by sharing that many disorders like borderline personality disorder are caused by complex trauma.
Back to fight, flight, freeze. Meredith re-iterates that we see all of these responses with eating disorders and these behaviors are attempts at finding ways to regulate emotions when they feel too much or nothing at all. She explains that another way to understand these responses is to think of the body becoming the scape goat for difficult emotions.
Jill shares a story she is reminded of from high school when her body responded to stress at a cheer competition by giving her the urge to urinate frequently.
Meredith goes back to trauma and eating disorders. She then talks about the treatment hierarchy. She says that an eating disorder client who is also addicted to heroine is certainly going to detox before getting eating disorder treatment.
She also shares an experience of working with a tricky adult client who wanted EMDR treatment. Though that client did not continue treatment for very long, Meredith recognized the treatment hierarchy in effect in her treatment.
Meredith puts trauma work in perspective in the hierarchy. ED clients who are eating better may find emotions are stronger because the ED is not masking their emotions, and then they may need more help in treatment to handle their emotions instead of their food intake.
Meredith recalls the experience of one of her long-term clients who had a history of ED, and was doing better with eating, but she had so much trauma in her life. Meredith was excited to use EMDR on her, but then she learned that the client had severe dissociation. EMDR would not work, so she referred to a dissociation specialist. Dissociation is something you need to refer out to a specialist for.
Jill asks how Meredith knew about the dissociation specialist. Meredith says she found the specialist through a lot of searching.
Jill says to keep people in your “rolodex” and the two laugh about old things that are obsolete today.
Jill summarizes that untreated trauma is going to manifest itself physically some way.
She also mentions that dietitians should assess clients thoroughly in order to really understand the client and take time (3-4 weeks) before deciding which treatment route to take.
In this episode, Jill and Meredith dive deep into body image and even divide into three different parts. They both discuss body image when working with clients, their own body image, and what the treatment provider roles are and how to address them. Meredith and Jill both go into the attitudes and emotions around body image; when to address body image in your sessions, what to engage in, and how to engage from a dietitian's and therapist's perspective. When discussing their own body image, they talk about how they personally deal with body image in the client/clinician relationship. They also go into clinician's roles and the education that is helpful to provide depending on their scope of practice. Do you as a clinician know how to handle body image? Is it realistic to always have a positive body image? Listen to our take on body image and how we as seasoned clinicians deal with body image in the field of eating disorders.
Season 2, Episode 33: "Dear ED Self"
Jill opens by reading a letter to “Dear ED Self”. The letter describes what benefits and drawbacks some may see that come from their eating disorder. The letter closes by saying goodbye to the ED self.
The letter was actually written by one of Jill’s clients who has worked very hard to overcome her eating disorder.
Jill gives a little more background on this client, and this transitions into the topic of how to know when it is time to discharge a client.
They discuss how the length of treatment may vary more in the world of treating eating disorders. As an example, Jill shares that this particular client was highly self-motivated and was able to move on from regular meetings with Jill in 2-3 years.
They both agree that clinicians must look at larger chunks of time on order to see true progress. Do not expect the progress trend to be obvious from session to session (days or weeks). When Jill sees that clients are progressing, she slowly transitions them off of appointments, moving from weekly or bi-weekly to monthly, and then eventually every three months. This only occurs when behaviors have been on the back burner for 3-6 months. Meredith says that with therapy, she may skip a week or two with a client when she or the client is out of town, and then if the client does well with a longer time between appointments, she may move to less frequent appointments at that time. Meredith calls her discharged clients “as-needed” clients. These are people who are doing well, and regular appointments are getting in the way of them “living their best lives” more than anything else.
Jill explains that at this stage, ED thoughts and emotions may still come up, but behaviors are very stable.
Jill reads the end of different letter that the same client wrote to Jill. The last phrase reads: “I AM RECOVERED.”
Season 2, Episode 34: Death of a Client
Meredith and Jill both acknowledge the high death rate among ED patients and what a somber topic this is. Both have experienced the death of a client. Today they hope to offer resources for clinicians who face these tragic events.
Meredith lost her first active client in 2019. It rocked her world, but she wants to help other clinicians based on her experience. Jill worked with one client in a treatment center who passed away, and another inactive teen client of hers committed suicide. Jill said she lets herself go through the grieving process. She asks Meredith what works for her. Meredith explains that she focuses on relationship building when she gets a new client. She acknowledges that therapists need to have boundaries, but she did attend the funeral for the client she lost, and she continues to keep in touch with the family of the client. Meredith also processed her grief in her peer consult group where she spoke to another therapist that specialized in grief. The counsel she received was that a clinician can decide for themself where to draw the boundaries with client relations. It’s okay to attend the funeral, and it is okay not to.
Jill points out that it is important not to lose hope for a client unless you have both agreed to do palliative care. Even people who have been in and out of treatment for many years can recover fully. She also reminds that you can always refer out if you are not best suited to treat a client. Jill and Meredith wrap up by advising that supervision and collaboration can be extremely helpful to support you with clients in these difficult scenarios.
Season 2, Episode 35: Understanding Metabolism
The spotlight is on Jill today as she discusses the science of the body’s metabolism and how an eating disorder affects it.
As a therapist, Meredith feels that her comfort level for talking about the science of nutrition is very small.
Jill says that this topic really highlights the need for a dietitian in treating an eating disorder. The dietitian has the best educational resources for the client when it comes to re-feeding and meal planning because the body is so complex.
For those who may need a dietitian for their eating disorder but live in an area where there aren’t any around, she mentions that virtual sessions now allow dietitians in other parts of the country to meet with clients in many different states where dietitian licensure is not required.
Meredith praises a blog post from Jill’s website called: “ Why is It Important to See a Dietitian that Specializes in Eating Disorders”. View the post at this link. Then, Meredith opens up the meat of the discussion by asking Jill to tell us about the basics of metabolism.
Jill says that metabolism is how our bodies use energy in order to function for life. Our needs change based on things like sex, age, musculature, and physical activity patterns. Jill worked in the dieting industry during the first part of her career and she still uses a lot of the concepts she learned in that industry in her sessions with clients now. However, she words thing differently by saying “energy” and “nutrients” instead of common diety words like “calories” and “macros”. She then explains that the human body is very complex, and the idea of the metabolism being “calories in, calories out” is just false. She says that what we often see with eating disorders disproves “calories in, calories out.”
She gives the example that even though many of her clients are eating enough to lose 10 pounds per week, they only lose 1 or 2 pounds. Why is this? Our bodies change when dealing with the stressor of starvation. The metabolism speeds up or slows down to help the body survive. For more on this topic, she recommends Jennifer Gaudianni’s blog posts about, “The Cave Person Brain” found here.
Jill goes back to the basics and teaches that energy in is anything we eat or drink that has calories. Expenditure is activity, exercise, bodily functions that break down food, activities of daily living like work, self-care, etc. Expenditure is also the resting metabolic rate. In more detail, the resting metabolic rate is the amount of energy our bodies burns while doing absolutely nothing. Women tend to have a resting metabolic rate of 1200-1400 calories, and for men it may be 1500-2000 calories. Jill points out that even “safe” diets put your intake below the RMR, so the body thinks something is seriously wrong. Hair loss, menstruation loss, etc. begins. This is part of the body slowing down as it essentially adjusts to starvation. Eventually, the body will need less and less energy in order to lose weight. This is true for someone on a diet, AND someone with an eating disorder. Jill then breaks down the energy needs of some basic body systems as percentages.
Her main point is that the body adjusts to starvation because of its need to feed essential organs and survive. Our metabolisms are not just “calories in, calories out.”
Meredith’s takeaway is that she should leave this stuff to the dietitian and refer her clients to someone like Jill.
Meredith asks another questions related to metabollism:
First is the idea of hypermetabolism. When a client is on a meal plan but not weight restoring. She often thinks there are sneaky behaviors in most of those cases that are still going on that are preventing weight gain. So, she asks Jill if being hypermetabolic in recovery is legitimate.
Jill says it absolutely is. Speaking about outpatient experience, this resistance to weight gain doesn’t last very long when clients are honestly following their high energy meal plans. If the “hypermetabolism” lasts for months, she starts to do more digging about behaviors, and she relies on the therapist to do some digging as well.
Meredith concludes that she should have a healthy dose of skepticism if the hypermetabolism last for months, but recognize that it may occur very legitimately for a few weeks.
Jill goes on to talk about the importance of waiting for a while to incorporate strategies like intuitive eating because those who are recovering from an ED may not be able to trust their bodies and their metabolism for a while.
Then Jill goes into the last topic that she wants to cover. She says that some clients are weight suppressing. They are supposed to be in a much larger body, but they have been restricting to keep themselves in a somewhat “average” looking body. They don’t look emaciated, but they used to be 40 pounds heavier before their ED. In these clients, their weight may shift dramatically as they normalize their eating patterns. This doesn’t mean the metabolism is broken, but they may recover to their natural weight plus more. Be considerate that many clients will not have the typical anorexia traits.
Meredith give another plug for seeking a dietitian no matter where you live because telehealth may be an option.
Jill then reminds us that malnutrition or significant weight loss can cause cognitive changes and therapists should also consider this.
[REPOST] Season 1, Episode 21: Compassion vs Colluding
In episode 21, Meredith and Jill discuss the difference between compassion vs. colluding when working with a client struggling with an eating disorder. Compassion is used to help the us connect with the client and validate where they are at in their recovery. However, clinicians must continue to push and hold the client accountable to the recovery process. How does a clinician avoid aligning with the eating disorder? What are signs that we are colluding vs. being compassionate? What are reasoning clinicians will often collude with a client's eating disorder? Understanding how to give compassion rather than collusion is vital to being an effective clinician.
Season 2, Episode 36: When to refer to higher level of care
The dynamic duo will present education and resources on the topic and then present some of their own experiences referring clients. Meredith emphasizes that they will only be giving guidelines because eating disorder treatment is complex and every case is different. Recommendations are not “one size fits all.”
However, the APA does provide clinicians with some excellent approved guidelines.
Jill will discuss the medical and weight categories of these guidelines. But as a caveat, she mentions that people often come to outpatient providers first. While big treatment center corporations have people trained just to screen people who contact them and recommend a level of care, when they contact outpatient offices first, providers in this setting also need to know how to identify which treatment level is appropriate.
To gain a little medical information from new clients, Jill often takes their pulse, weight, and sometimes blood pressure. Based on those measurements, she may refer them to get a full medical evaluation.
According to the guidelines, a pulse of <60 bpm in adults and <40 bpm in adolescents is criteria for admittance to a treatment center. These rates get lower while sleeping. For weight, Jill does not use BMI, but she uses % of usual body weight and growth records (for adolescents and young adults especially). She often recommends inpatient for people less than 80-85% of usual body weight.
Meredith then goes over the referring criteria on the therapy side of things. She looks at many possible psychological issues that could heighten the level of needed care, like suicidality, motivation to recover, cooperativeness, insight, ability to control obsessive thoughts, level of severity of depression and anxiety, OCD, PTSD, substance abuse, etc.
Essentially, Meredith says that the client also needs a higher level of care if they are struggling to get mentally well or improve in an outpatient setting. She also mentions that the amount of social support a client has also makes a huge difference.
As final thoughts, Jill says that the number of clients you have seen helps you build your instincts that tell you when someone needs a higher level of care. She advocates for supervision because new dietitians may not have this instinct yet, but a supervisor does. Personally, Jill has worked with clients on an outpatient level who, according to the APA criteria, needed a higher level of care. But, through a great treatment team and support system, she has helped them improve on an outpatient level. Some of those clients have still gone to some form of higher treatment eventually, but she has helped them progress far enough to avoid going straight into acute level treatment. She also suggests that if you are unsure about referring, try working with a client for 3 or 4 weeks before coming to a strong conclusion about whether or not to refer them to higher care.
Meredith agrees that supervision can be extremely helpful.
Season 2, Episode 37: Crowd Sourcing, Anyone?
Jill opens by talking about a Netflix series episode she watched that included a physician using an online chatroom to crowdsource ideas for a difficult diagnosis.
Her point in bringing up the show is to warn clinicians not to crowd source for ideas about difficult clients on Facebook groups, or other online open forums. She explains that people often release too many details in these groups, and those releases can easily become HIPPA violations that clients can come after a clinician for if they end up finding a post made about them. She recommends seeking a supervisor instead. It is a much safer option, though you do pay for the service.
Meredith agrees that protecting client information is a huge priority. She also points out that you may not know how qualified or reliable the people are who are responding to your posts on Facebook or in a chat room, but if you have a very general question that pertains to a large group of possible clients, asking that question in a Facebook group may be appropriate.
Jill says that she goes to other clinicians for support and supervision herself, though she supervises others as well. She also thinks a helpful supervisor or peer group is not full of people who just tell you what you want to hear. They should be people who are able to challenge you to change what you are doing.
The episodes close with both Jill and Meredith pleading for clinicians to stop posting about clients on Facebook.
Season 2, Episode 38: All in a WORD
Jill and Meredith reflect on how their podcast has been doing, and they mention a comment they received from a listener on their recent episode, entitled “Death of A Client”. Meredith expresses gratitude to this commenter who called them out for using an inappropriate term while talking about suicide, and she apologizes on behalf of the platform. Jill also thanks the commenter for pointing out their error because she had never realized that the term used was inappropriate.
Jill transitions from this situation to the topic of the day’s show by explaining that the language a clinician choses to use while treating eating disorders is very important. First, she discusses talking about obesity and how differently she used to speak about it when working in a clinic for weight management earlier in her career. Now, when working with an eating disorder client, she never uses the word “obesity”. However, when working with a physician and speaking about a client, she will not correct them for using the word.
Jill talks about how “obesity” has become kind of like a swear word in the world of eating disorders, but she also realizes that the eating disorder world is still quite small, and though she needs to promote body positivity with other medical professionals, she can’t expect those outside of the eating disorder world to know how to use the most helpful jargon.
Meredith thinks about the question from DBT: Do you want to right, or do you want to be effective? She tries to carefully consider her tone when speaking with medical professionals about clients, but she doesn’t know if thinking of obesity as a curse word and treating it as one is effective for her. However, she certainly would not use that word on her website or when meeting with clients.
Jill says that clients begin to pick up on positive language from their clinicians as they notice the different jargon being used.
Another word that Jill brings up is the use of “and” instead of “but” in a sentence. The “and” does not cancel anyone’s thought or idea in the way that “but” does. Meredith adds that sometimes “because” can also replace “and” in a helpful way as well.
As a dietitian, Jill says she uses “energy” instead of “calories”. She says it is a huge deal for clients to realize that giving their bodies energy is a good thing. Jill also never says “weight gain” because this can alarm many eating disorder clients. Instead she uses “weight restoration”. Meredith adds that we should identify disease states in a person-first way by refraining from calling them “anorexic” or bulimic” and instead saying that the client is “a person with anorexia” or “a person with bulimia”. Similarly, she has learned not to label a client as “resistant” or “non-compliant”, but to instead describe exactly what the person is struggling by saying things like “he is struggling with a lot of fear”, or “she has been struggling to complete her meal plan this week”.
Jill brings up “fat” and “skinny”. She usually uses “larger body” and other gentle terms unless she learns that the client is comfortable with words like “fat” or “skinny”. Jill references Amanda Holden and remembers that every client is different. She also mentions that each client is your best textbook for treating that them as an individual. Some words may be more appropriate for one client than another, and clinicians need to take the time to learn each client.
Season 2, Episode 39: Macros 101: Understanding carbs, protein, and fat
The spotlight is on Jill today for this nutrition topic. She will talk about “counting macros” and the basic nutritional science of the three macronutrients: protein, carbohydrate and fat.
Meredith is excited for this topic because lots of people share with her that they are “counting macros” and she wants to know what it means.
Jill’s main points:
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Initially giving a new eating disorder client education on intuitive eating may not be appropriate. The initial education they need is the basics of nutrition.
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The three macronutrients are carbohydrates, proteins, and fats. Bodies need these in large quantities. Micronutrients are all the vitamins and minerals. These are needed in very small quantities. ED clients often avoid carbohydrates and fats most because they associate these with weight gain. This avoidance quickly leads to malnutrition.
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How do you count macros? Macronutrients are measured in grams. “Protein foods” just have more grams of protein in comparison to most foods, or in comparison to the other macronutrients they contain. Counting macros just means keeping track of the number of grams of each nutrient eaten per day, and usually people are trying to stay under a limit set by a trainer or an app to assist with body building or weight loss.
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Why do we need these macros in our body? First, our brains primarily survive on carbohydrate. Carbohydrate is also the preferred source of energy for the rest of our body, so we need more of this macronutrient compared to the others. Protein is needed for rebuilding the muscle, tissues and structures. It is not the primary energy source, but the body can use it for energy if needed. Fat is necessary for some energy expenditure, the absorption of many micronutrients, and it enhances the taste of food as well as creating a longer feeling of fullness or satiety after eating.
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Typically, eating disorder clients will not have a proper distribution of these macronutrients.
Meredith finds this information very helpful because she now has a basic understanding of what clients are talking about when they try to avoid feelings and discuss food with her. She also better appreciates more how important it is for her clients to also have the dietitian as the nutrition expert on their treatment team.
Jill affirms that the information she has shared not her opinion, but scientific fact. However, it is important for her as a dietitian to listen to client preferences and opinions to navigate their treatment effectively.
Season 2, Episode 40: Good "Jill" Hunting
It’s time for Meredith to take over the spotlight again! Today she will go into more detail on models of countertransference. Meredith starts by talking about an Ethics workshop for therapists that she attended in which countertransference was covered.
Jill thinks that talking more about countertransference is a great idea—especially because dietitians who may have limited knowledge about it and they will likely need the skills to manage it in session.
Meredith reminds that countertransference refers to our own personal thoughts and feelings that come up while we are in session with a client. Examples include attraction to a client, a client reminding you of a loved one, etc. She says countertransference is not bad, but clinicians need to know how to manage it through supervision, their own therapy, etc. Do not process it with the client. Though, Jill and Meredith discuss that you can sometimes use your own thoughts and feelings to inform your work with the client.
4 Models of Countertransference:
1. Empathic Disequilibrium: This is where clinicians feel like they are not making any progress with the client, they feel guilty, and there may be role reversal where the client reassures the clinician because they seem to be feeling ineffective or incompetent. Meredith uses an example from the film, “Good Will Hunting” to illustrate this.
Jill comments that she feels this kind of countertransference happens more when you are new to the field, though she still experiences it at times even after years in the field.
2. Empathic Withdrawal: This often looks like a therapist with a flat affect, but who is only putting it on to self-protect or self-contain. Meredith says clients can tell when you are doing this because they are very perceptive. Meredith’s example for this comes from her own experience. She once had 3 teen clients in a row, and through various interactions with them, she felt her buttons had all been pushed and she had been disrespected. She withdrew in order to “stay professional”, but she realizes now that she was only withdrawing to protect herself. Jill asks what Meredith’s behavior changes looked like. Meredith provides that she found herself becoming quieter in session and providing more validation and soothing when she should have pushed the clients. Now she recognizes that she is more able to push client when she uses fun facial expressions and humor.
3. Empathic Enmeshment: This occurs when the clinician over-identifies with a client. Boundaries are more easily crossed when enmeshment occurs. Meredith gives an example from a video clip in which a female therapist is attracted to a male client and feels they have a lot in common, so she replies to his text messages at midnight. Meredith emphasizes that what is most important with this countertransference is to know why you are doing what you are doing with a client, and seek supervision if you recognize a problem, and then correct it.
Another way this enmeshment comes up is in too much self-disclosure, or the clinician talks too much about themself in order to relate to the client. Meredith shared a tool she learned from the workshop called the “5-second rule” for self-disclosure.
4. Empathic Repression: Meredith says this is related to the withdrawal kind because the clinician avoids certain topics or content in session because they are too emotionally charged or upsetting. Meredith discloses that she has to watch happy television while working with trauma clients because she has to prepare herself to hold space for all that the client needs to share in session. Jill shares a few of her own examples of confronting potentially uncomfortable situations in which clients share things more suited for therapy. As a dietitian, Jill will usually hold space for their emotions, thank they for sharing, and ask them to please bring the topic up with their therapist.
Meredith recommends that dietitians have some emotion coaching statements in their back pocket and use them to help the client have a positive experience, but also refer the client to his/ her therapist. She says the dietitian can also ask about how the shared information relates to food in order to re-direct the conversation to what is within the dietitian’s scope.
The session closes with Jill sharing about her TV preferences. Her entertainment choices are very different from Meredith’s.
Season 2, Episode 41: Tummy Troubles
Jill starts out by referring to several other podcasts that go into depth on the issue of stomach issues while being treated for eating disorders. She says to listen to Christy Harrison, MPH, RDN, CDN (follow this link to podcast episode: “Food Psych #175: The Truth About Digestion And Gut Health With Marci Evans”) and Jennifer Gaudiani, MD, CEDS, FAED (visit this page and scroll to episode Titled: “Eating Disorder Recovery Podcast: Ask Dr. G: Tummy Troubles in Eating Disorder Recovery”) in particular.
Jill goes on to talk about her experience as a dietitian at Ben Taub. She covered pediatric, PICU, NICU, and Surgical and Medical ICUs while there. Once while talking to an adult after being on the pediatric floor, she used the word “tummy” while talking about his stomach. She then refers to Julia Ender’s book called “Gut” and recommends it as a great read about all the organs in our digestive tract. (See book on Amazon here.)
Jill has a particular interest in talking about how emotions (stress, anxiety) are very frequently connected to GI distress.
Basically, Jill explains, the brain is connected to our peripheral nervous system, so our feelings and emotions impact how the rest of our body feels. Sometimes this connection leads to sweaty armpits or hands during a time of high stress, and sometimes people feel stress in their stomachs. She reviews the sympathetic (fight or flight—engaged in high-stress situations) and parasympathetic (feed and breed—activated in a more secure or relaxed situation) nervous systems and explains that when stressed clients are always operating with an activated sympathetic nervous system, they are never going to want to feed (eat) or breed (fully engage in relationships).
Meredith reminds that tummy troubles are relatable for all of us, and they are rarely caused by one thing.
Jill wants to talk about how dietitians should approach tummy issues with new clients. She says you have to try to get the whole picture. Pay attention to their history with eating and how it has changed, look for “food allergies”, avoidance of food groups, introduction of new supplements, lack of variety, etc. Be sure to educate the client on the gut and be aware that it often takes several months for the gut to adjust back to normal eating with proper quantities and variety. Jill remembers one client that thought she was allergic to everything, but they later found out that she was only allergic to milk. The “allergic reactions” often resolve as the ED is treated and restriction stops.
Jill says that many dietitians feel they do not have enough in-depth knowledge about all of the issues that can occur in the gut and hesitate taking on clients with a primary complaint of stomach issues. She says you don’t need to have in-depth knowledge. Just know when to refer out. However, with ED clients, the issue is often the disordered eating, and not something else.
Meredith says that she is very careful and makes sure to validate the discomfort that clients feel and share about in therapy, and doesn’t want them to feel they are being told that their physical distress is “all in their head”. She recognizes that often times their discomfort stems from emotion, ED behavior and other medical issues combined. She teaches somatic skills to help clients get in tune with their body, and she practices deep breathing with them in the beginning for anxiety and stress. These tactics usually lead to the client sharing more about emotions and realizing after a while that their emotions are connected to the physical symptoms they were feeling.
Jill says that outpatient dietitians in particular need to understand that it will be a slow process to get clients back into intuitive eating when their sympathetic nervous system has been on fire for so long. In closing, she reminds dietitians not to be intimidated by these tummy issues, but to know when to refer out.
Season 2, Episode 42: Grand Finale: Encore Please!
This will be the last episode of Dietitian Seasonings and Therapist Reasonings. Jill and Meredith wanted to dedicate this episode to thanking all of their listeners. They have decided to discontinue recording new episodes because they feel they have accomplished what they wanted to with the podcast, and they are now going in different directions with supervision.
Because Jill and Meredith are both IADEP certified eating disorder specialists, Meredith offers a plug for IADEP resources that can be found on the IADEP website.
Jill mentions that there are many supervision groups out there to offer support in addition to IADEP’s resources. She hopes this podcast was not the only resource any of the listeners have been utilizing.
Meredith wants all listeners to know they are welcome to continue to get in touch. She shares that Jill has a residency program available to registered dietitians who want to gain experience in the eating disorder field. Resident dietitians in Jill’s practice get to meet with real clients and receive direct supervision from Jill. Jill has more information on her website about this program and how to apply: https://www.jsechinutritiontherapy.com/residency
Anyone who wants to reach Meredith can email info@harmonytherapygroup.com or visit www.harmonytherapygroup.com. She is now spending a lot of time developing e-courses and trying to become a continuing education provider. During these COVID times, Meredith has been spending a lot of time on continuing education and has enjoyed it very much. She still offers IADEP supervision as well which comes with access to her e-course on how to market a private practice.
Meredith invites all listeners to say hello when they see Jill or Meredith at conferences, etc. They would love to hear from you! Ciao!