Eating Disorders: The Team Approach Brooks Morse

well good morning anybody in here morning person no well I am so hopefully I'll have enough energy for all of us way I like to do this is I like for it to be very interactive I don't like to go by I have some things I want to talk about and I tend to do it more sort of like a conversation and so I really hope that you ask questions along the way feel free to stop me I think that makes it much more informational to you all and you get your needs met during the discussion the things I'm going to focus on today are there's a couple of things one is what is our approach to eating disorders in a sense why do we think eating disorders develop and based on that how do we intervene how do we intervene as a treatment and treatment team as well as prevention and then within that talking about our approach that sort of sets us up to explain why we need to work together and why we need a multidisciplinary team to work particularly with eating disorders then I'm going to talk a little bit about our services so in a sense you know what we're doing with the same people you're working with and I'm going to talk about what's been so helpful through you as a nutritionist working with eating disorders what I have found to be really helpful in the treatment of our eating disorder clients and so going to talk a bit about that and basically the whole presentation today is to have the left hand in the right hand sort of know how they're working together and talk about how important you are to the work we do with people with eating disorders so that's going to be the main focus how many of you have ever known anyone with an eating disorder a friend a family member okay so quite a few how many of you have ever read anything or heard about eating disorders in your classes okay everyone and the next one you don't have to raise your hand but I just want you to answer it silently to yourself how many of you have ever struggled with body image issues have ever not felt good about what you see in the mirror how many of you have tried a diet and just felt like it failed and like you were failure okay my guess is that if I had done hands there probably would be quite a bit because about ninety-eight percent of women have been on a diet before and have struggled with body image issues so what's real important about this right here is that everyone in this room has some familiarity with eating disorders and also with dieting and body image issues which are part of eating disorders so you already have a lot of personal experience or personal information that can help you understand where this person is coming from that can help you relate to them and be empathic to their situation and that's really important the rest of it you can always learn but this piece sort of needs to be in place first let me tell you a little bit about my first experience working with people with eating disorders I was working at a federal prison and I was working on a substance abuse unit doing a lot of group work and it was a female prison so it was all women and I was doing a lot of group work around trauma issues doing a lot of group work about substance abuse issues and I hadn't learned very much about eating disorders to that point and then about half my group had eating disorders now my first you know reaction was oh my gosh what do I do this person could die I felt very overwhelmed even with all the training I already had in psychology and counseling I felt scared by the medical consequences I felt like I had to fix this right away I felt a real urgency now I don't know if any of you can relate to those reactions as you think about possibly working with people with eating disorders but it's real common for health professionals when they're first faced with someone with an eating disorder to feel how lesson to feel scared and overwhelmed now my reaction to that was I went and learned as much as I could which is sort of my style when I feel helpless is I read everything I got special supervision and all that really did help but I think what helped the most was sort of the questions I asked you initially what helped the most was for me to sort of put my helplessness aside and say you know I can relate to this person as a woman dealing with body image issues in my past and this person has gone this long with this eating disorder which is often years and has survived and has functioned and yes there are some really serious concerns here medically that need to be addressed but this person isn't going to die tomorrow and so I need to slow down and I need to not try to fix it which is just going to push them away and it's going to make them feel like their failure and I just need to be with them and start from there and that was the most important thing that I recognized so I want you to think about that too the other thing I learned from being on a substance abuse unit is how many of you have heard that eating disorders are an addiction anyone ever hear that anywhere well that's where I started out I started out in an addictions model and what I found is it doesn't work and I found since then I've realized that's not what causes an eating disorder but at the time I just realized the treatment didn't work I mean to try to say to someone abstain from food you're physiologically dependent on food and also the addictions model basically just looks at the biology and there's so much more it's so much more complicated eating disorder what I found is is I try to control them through abstaining from certain foods carbohydrates or whatever and ask them to give up control in this addictions model that what happened is they try to gain control more and restricted more and purged and binge s'more so I found that didn't work and what I've learned since then and the model that we use at the Counseling Center and the program that we develop about two years ago is that in reality and what the research supports is that eating disorders are multi determined and what that is it's a biopsychosocial model of where eating disorders come from and I'm going to explain that what that means is there's some predisposing factors that set up a person to have an eating disorder there's individual factors there's familial factors and there's cultural factors within the individual we have sometimes but not always we may have a trauma history that could be anything from sexual assault childhood abuse adult abuse or it could be parents divorce it could be a really very traumatic breakup with a significant other a death in the family having someone else in the family is sibling which I find at times have some pretty traumatic stuff going on and so you the person has the eating disorder is sort of dealing as a secondary person with this trauma that their sibling is going through maybe a physical disability maybe that person has a psychiatric disorder and so this is the way they deal with it personality factors probably all you have heard about you know someone with an eating disorder maybe being more perfectionistic wanting to be in control being more passive or wanting to please others each person is very different and I think that we need to not sort of generalize too much but there are certainly personality characteristics that might predispose someone and that plays into family as well that often there may be some family or norms of being you know in control of needing to go beyond what's realistic and expectations not know not learning how to deal with feelings in a healthy way and so always stuffing them those kinds of things that maybe a family culture brings up the other thing with individual and family is biology in that sometimes we're often finding now that people with eating disorders have someone else in the family with an eating disorder or in their history someone with depression someone with an anxiety disorder so there's a possibility of certainly a genetic link but I think also with the biology and what we're seeing in families is that we're seeing an increase in eating disorders now well guess who their mothers were and their grandmothers the grandmothers are the ones who started Weight Watchers how long have diets been around anyone know yeah just about actually in the 70s close to that in the 70s is when Weight Watchers was sort of that first formalized diet came out the formal structured since then the dieting ads have increased huge amounts Jenny Craig slim-fast and you all know in this room just how well they work instead of healthy eating habits so we have all this dieting going on so they're learning in the family they're learning from their mother or from their father certain eating habits certain restriction certain things about body also once someone starts dieting which I'm going to talk about that also sets them up biologically for an eating disorder culture there's another reason eating disorders start to come around in the 70s anybody know who is our famous model in the 70s sorry yeah Twiggy and you will never see a picture of Twiggy she looks a lot like Kate Moss and we started to have a lot of young girls who wanted to look like Twiggy and so we have all the isms we have sexism we have homely of homophobia we have racism we have classism and we have but particularly sexism playing into the cultural reason for eating disorders so this is why I don't think an addictions model works it's just too linear and this is the other reason why we need all of us on the treatment team we need the physician for the biological medical consequences and times any and we need the psychiatrist at times for any depressants or anti-anxiety we also need the nutritionist which is actually the first person I tend to refer to even before myself or a physician to help with the nutritional aspects and the food and the dieting and to challenge that and we also need the therapist both individual and group to deal with sort of the personality the trauma issues but as well as the cultural issues as well as sort of challenging what what young women think of as what their worthiness that their body size and their weight equals their self-esteem and to start challenging that to start challenging that you know culture defined that we can question that anyone know who is a famous model in 1950s very adored by our society probably the most adored actress and model Marilyn Monroe size 16 Twiggy and Kate Moss have not been our ideal forever that was created by our society and we can just as well uncreated we have some control over that so this is the biopsychosocial model now these predisposing factors turn into perpetuating factors with the eating disorder what happens is someone may have all of these and they're sort of set up then what do they do they start dieting what do young girls learn as a way of feeling better when the rest of their life doesn't feel good well I have control over my body I don't have control over anything else I don't have control over my parents getting divorced I don't have control over these feelings because I never learned how to deal with them but I can look better and whether they're conscious of it or not Society has told them that women get a lot of bonus points for looking thin and looking attractive so I'm gonna feel good through dieting over 50% of people with eating disorders said that dieting was the main trigger so they start dieting the other thing that goes with it is dissatisfaction with body they start looking at their body through puberty or a little bit after and they start saying oh my gosh I've got hips oh my gosh I got a little tummy and we're learning through culture I mean how many of y'all think that women are supposed to have flat stomachs yeah it's not normal but we don't get that what we get is normal is through all the models that actually they airbrush so these aren't even true real people we're looking at is that our stomachs are supposed to be flat we only get exposed to one body type and it's a body type that fewer than 10% of our population naturally has and so we start getting very dissatisfied with our body we start looking at her body and saying oh my gosh it's terrible I don't feel good about all these things in my life or some things and so I'm gonna diet and initially they feel really good oh my gosh I lost 5 pounds oh my gosh I feel so much better I got compliments I lost weight it's very reinforcing but what happens is through that dieting as you all know it becomes more restrictive over a year they not only now cut out fats they now cut out carbohydrates as if carbohydrates are evil and then they're going to cut out protein and finally all we get left is maybe a little bit of fruit and some salad once in a while and so it just starts going down and they want to lose more weight and the weight they thought they'd be happy at becomes less and then what happens is they feel so starved and hungry and they're obsessing about food all the time that they start binging because they can't help it they get set up for this eating disorder and that's another really important point that we make at the counseling centers that a lot of people feel so ashamed and weak when they finally come in and get help because I feel like I should have fixed this I'm responsible I'm making my whole family suffer and all my friends and I caused this and why can't I stop it and they're not weak they're very strong for coming in they're very strong for reaching out to help because it goes against all their perfectionism and feeling like I should be totally in control of myself that took a lot occur and often I've seen very few people although I have seen it happen people actually recover from an eating disorder without getting some kind of help from some health professional it's very difficult you just can't like all their friends often say well just deep it's not that easy it's very difficult food becomes very symbolic of a lot of fears for them so that's our approach any questions about biopsychosocial model before I talk about how we interact as health professionals any questions reactions everybody so quiet is this familiar to people or is it new at the height of her career she certainly changed body types because she went back and forth through her own dieting someone yeah if you ever see a picture of Marilyn Monroe in the low bathing suit she has that bathing suit she has it tummy it's great she has hips and she's a very beautiful woman but we've gotten we've been so what's the word rich we've been so yeah brainwash is a good word but brainwashed to think that this one type of body is attractive that we start believing it and what would the world be like if we were never told a certain body type was attractive and we were exposed to all different kinds gosh that would be interesting we might see beauty in every form in shape that would be neat that was that your question now I know this is familiar to you Katy was part of our eating disorders outreach team which was fun we go out and do prevention and sometimes undergrads come and help and we go out and do presentations so she's been up here with me before okay I want to turn to this our treatment team approach and it's a handout you have it's a Venn diagram it is it in their book okay it's in your book I'm gonna hold it up Eunice was nice enough I used to do this on the board that she actually did it out for me this is a Venn diagram of kind of held the physician psychiatrist has one circle you as the registered dietitian or nutritionist has another and I as the therapist has another circle and we have some overlapping areas as the therapist I'm going to focus more on issues like self-esteem all-or-nothing thinking trying to help them find middle ground looking at replacing the eating disorders at coping you know doing some assertiveness or stress management whatever is actually triggering eating disordered behavior I'm going to try to help them deal with psychologically deal with through changing behaviors changing their thoughts or expressing their feelings a lot of what I'm doing as well besides sort of challenging that rigid thinking and that all-or-nothing thinking about themselves their whole world and like I said there's a lot of some symbolism with how they eat and how they deal with the world in relationships I'm also going to be working with them on healthier relationships and we do this a lot in group and sort of helping people relate to each other and talk about what that feels like often a person's intimacy decreases with others they isolate they feel very ashamed of themselves and they're not quite sure how to connect to others and so we deal with that in a group situation also talk about family issues or trauma if that is pertinent sometimes it's not sometimes it's not but a lot of times there's at least some messages that of course you're going to be handed down to the family from our greater society that the person learned that doesn't mean that their parents are bad they may have had a wonderful upbringing but it we just can't live in this society without having some of these thoughts and norms impact us so we just talked some about that a lot of what we're doing is psychologically helping them put control on the inside in a sense trust themselves listen to their feelings listen to their senses and begin to be more aware of that rather than looking to the outside looking to the models looking to what other people think of them making incorrect assumptions about themselves through external world and help them look inward at the same time you down here are doing the same thing and putting control on the inside through food embody you're helping them know when they're hungry you're helping them see that when their body actually craves peanut butter they may have not eaten pumped in a long time or that fat helps them sustain a longer time period because it helps them feel fuller you know so you're helping them understand how food is very important for their body and that they can trust their body on that you know our bodies are a wonderful creation and when we take control outside of the body and we put it on the clock or we put it on we put it on calories or we put it on the scale we're really taking control out of a machine that works lovely for us and it's very intuitive and so by doing that we really mess up our body to the point where they don't know what normal eating is anymore they wouldn't know hunger if it hit them in the face and where they don't know what a normal kind of healthy weight would be and so you're helping them do that we may start by talking a bit about calories and giving them a reality check that you know most women eat about 2,000 calories a day give or take we give them a reality check by saying you know 96 pounds is not probably enough but in the end what we work towards is having them decide when they're hungry having them listen to their hunger cues having them listen to their body's needs so we give them some structure in the beginning but work towards that work towards them throwing out their scale and just deciding when their body feels good and can work well rather than a number so we're both working on food and feelings thoughts but the sort of the whole philosophy of what we're trying to do is very similar now that physician psychiatrist is dealing more with those medical complications and believe me we refer to physicians quite a bit so that way both you and I can feel a little easier about is this person in any medical danger and have that person take care of it so each of us sort of knowing the other person is working on a different part helps and allows us to feel less overwhelmed less helpless and feel like we can really focus on what we're doing I feel really good knowing that you all are working on the nutrition because then I don't have to work as hard on that part and also I know someone else is giving this person the message that they're that healthy eating is important and not restrictive eating is someone else is giving that message that they don't have to be a size four to be a worthwhile person I was telling rich I was telling rich the other day I think that one of my clients are in the training for the interns that one of my clients I kept saying you know she was starving every night she was so hungry she probably ate about 1,200 1,500 calories a day but she was so hungry and she'd been doing this restrictive eating for quite a bit and she's like but I eat enough I eat three meals a day well they were very small meals and I kept saying you know I think your body's telling you something you're tired you feel weak I think you're not either getting certain food groups and I don't think you're probably eating enough would you be willing to see a dietician well okay so she goes to one of y'all a couple it was like a couple years ago and she comes back after the first session and she looks at me and goes if it's a whole new concept Brooks I'm not eating enough did you know I need to eat more I need to have snacks throughout the day I need more of you know I need more carbohydrates and protein and I'm like that's great that's great you've learned that but you have more credibility than I do with that it's very different to hear from a psychologist about food than from a nutritionist about food so you play an extremely important role that even if I have a little bit of the same information which I don't have the amount of knowledge you do I still don't get that credibility so it's really important to be giving similar messages so we're all working together I want to cover a little bit where we overlap weight and culture and body acceptance before we do that anybody have any questions so far okay reactions coffee's not kicking in yet of course y'all being nutritionists maybe you don't drink coffee it's my one bad habit one other thing about how important you are before I start talking where we overlap several years ago I did I came in sat while a student she wanted me along just in case there was any fallout one of my old clients and she presented to some of her friends and shared with them that she had had an eating disorder she was concerned about some of them and talked about her recovery process and she was better people do get better it takes hard work it takes a multidisciplinary team but they do get better and so she was talking about this and you know the person she talked about the most is helping her her nutritionist it was one of y'all in the class a couple years ago just how important that person was they had similar units had matched him according to similar sort of hobbies and this person was just really helpful for her and really making the shift and eating more normally and she needed to eat more normally to do the work with me because when someone's not eating you think back on a diet you were on oh my gosh are so tired you're cranky you can't sleep I mean I don't know if y'all ever heard of that Minnesota study where all those men they starved we can't do that today but they starved them and guess what these men developed eating disorders surprise surprise they became cranky irritable depressed they started to binge they start to put ketchup in their food because they wanted a different taste they obsessed about food thought of recipes so you know people start feeling that way then it's hard for me to focus them on their feelings or changing some of their stress management when it's really hard for them to think real clearly so once they start eating more they're more able to do that so that was really important for that student that that dietitian in her made such a connection and helped her so much then once she started to eat more she and I could take off in our work which was great so if I can't say it enough y'all are very very very very very important so let me talk a little bit about weight and body acceptance if you can't tell I keep talking about this whole issue about body size and how our culture is really skewed well someone once put it to me this way and so I'm going to put it to you this way and it means so much sense it's me it's just it's amazing how brainwashed we get every other human factor is on our statistical bell-shaped curve y'all probably read that in your science classes our eye color our hair color other factors about us everything is on this bell-shaped curve well for some reason in our society we think weight is down here and that everybody should be it should be able to be a size two to eight or two to six that if we just work hard enough if we just diet enough we can change that body size we have as much control over our height probably it is a very natural by a very natural phenomena that many of us have different body types now it's true that many of us are in this average area of which the mean is not size eight its size 14 we're skewed on that too but some people are actually meant to be larger not the majority and some people are meant to be thinner not the majority but we seem to not only have skewed this over and thought the average is here but we seem to think that everyone can be over here and they can't some people are genetically predisposed so pre I'm gonna get this word wrong there predisposition is to be larger and I had a client once who was anorexic and she was about a hundred and sixty pounds five foot five now according to those wonderful metropolitan height weight charts she's overweight because of her genetic background because of her family history and growing up in a a stern European you know her parents parents have grew up in a Eastern European country being bigger boned she was to be a larger person she her setpoint range really was around one hundred and eighty she was getting ready for a wedding and so she kept dieting down she stopped menstruating at 150 pounds well that should tell us that she was probably below her natural body weight and so some people are meant to be larger what happens though you know we hear a lot about our society getting larger and larger what happens though is people start going on diets who probably are in a healthy range and what happens as you all know is they start gaining more weight and so they do become larger than they should be but if they had just accepted you know where they were originally and done healthy eating habits and a healthy lifestyle they probably wouldn't be as large as they are and so what are they here now oh I'm much larger I gained 30 pounds over the last three years I'm just not doing this diet right I just got to restrict more well that's not the answer we keep giving them the answer that actually causes them to gain more weight and causes them to feel like a failure and causes them to develop eating disordered behavior so one of the things that I'm trying to say here is that all of us need to get across is that there's different body types that's real important if we subtly give the message that they can be a size four if they just work hard enough that they should be a small person no matter what we do with them behaviorally or food wise we're giving them the message that yes you should continue this eating disordered behavior so it's real important that we're all clear on body acceptance the other thing is setpoint how many of you have heard about set point theory yes yes it's a wonderful theory and I'm just gonna sounds like many of you know it well would anyone want to say what it is if you work like really really really hard you might do yeah so for me I'm about a hundred and thirty pounds okay I eat relatively healthy I'd chicken wings last night but tonight I'm going to have carrots and a pork chop and some carbohydrate cell and fruit but you know once in a while we all splurge a little bit so I'm 130 pounds my weight if I if I get into a rut of exercising where I'm real busy at work and I don't exercise as much I might go up to around 133 not very likely not very often if for some reason I'm stressed out and I'm not remembering to eat as much as I need to I might go down to about 127 we got about three pound three to five pound men maybe a little larger range range and what happens is if I start gaining more my furnace goes up my metabolism increases because my body really wants to defend the internal thermostat of 130 and so my metabolism is going to go up to try to get me to come back down and like you were saying I might try to lose a bunch of weight what happens is my metabolism decreases the furnace starts to burn less because it's trying to hoard any heat it can and so what happens is my metabolism decreases so much and this is what sets people up for that weight gain that once I start binging which I'm either going to die if I continue restricting or I'm going to start binging it's just a natural response I'm going to start gaining more weight and even go over what my old setpoint was and maybe develop a new higher setpoint but usually we can stay right here the body just naturally defends that without any just living a healthy lifestyle and not trying to control one's food as much remembering the food guide pyramid which is great and using that but not trying so hard to cut out all ice cream all sugar all everything and so that's really important because the Metropolitan height weight chart it's just for a certain group of people it doesn't cover the whole range of body sizes you know anyone know how many times that's been changed in the last like 20 years five times so if they're accurate weights if these are really truly ideal weights why they keep changing an interesting point and I find a lot of people that I work with don't fit those height weight charts they're either really naturally a little bit smaller or they're not and most time it's they're naturally a little bit bigger so those are really important places intuitive eating that's another thing y'all are reading that book right that's another thing we really emphasize that the Counseling Center that sort of you know it's our overlap of course we're not going to sit down and do that with them that's y'all's job but we really reinforce that so that we're sending the same message that you are eat to hunger stop one fall really trying to get them away from numbers and trying to do more of that so we really emphasize that the other place we overlap is looking at middle ground because a lot of people with eating disorders have all-or-nothing thinking a lot of all-or-nothing thinking so we're helping them look at middle ground and their expectations of themselves you're helping them look at middle ground with eating know well this week yeah maybe you did you know restrict a little bit more but let's look at the big picture you know over the last three weeks that we've been meeting you have really you know you're starting to actually eat a little bit of carbohydrates that's great you know or you know maybe you can't start with 2% milk because that's so scary that doesn't mean you're a failure let's think of something else let's think of non-fat yogurt or skim milk and we'll start there and work our way up so really helping them see that the world is very gray and so we're doing that not only in the behaviors and problem-solving but we're doing that through our message that there's a lot of middle ground out there maybe they won't always get an e plus but C's are okay once in a while and maybe that particular partner didn't want to be with them and broke up but that doesn't mean there are bad