For Professionals

New Year's Resolutions

It has been some time since my last posting . . . apologies to all, especially my contacts at Gurze, who have been incredibly patient with me.  In addition to the extra events and travel during the month of December my family was plagued with some illness.  All of this made it difficult to find the time or energy to post.  When the time for New Year's Resolutions hit, I thought to myself that "doing better with my blog posts" was an excellent thought.  That was six days ago, and the "thought" never crossed my mind again. 

Holiday Tips for Helpers

Our Thanksgiving is over, and in a few short weeks, we'll be celebrating Christmas.  As we all know, this season brings special challenges for those individuals struggling with eating disorders and their families.  Lots of activity and family togetherness, along with special holiday meals, can raise anxiety as they are anticipated and depression when they are over.  Each year my staff and I spend extra time on the importance of good self care during this stressful period.  But how about those of us who are the helpers?

Response from Carolyn Costin

Carolyn Costin, Director of Monte Nido and Affiliates, and author of The Eating Disorder Sourcebook and !00 Questions and Answers About Eating Disorders responded to my last post about Professional Boundaries with these words:

"The topic of our relationship as clinicians to our clients is always a hard one to discuss. There are so many reasons for us all to be concerned about this dynamic. From the very beginning in my work with eating disorder clients I found that they needed to hear from me as a person, not just as a therapist. Although I am careful, I do talk about myself and share from my experiences . . . I do not share the horrors and dirty details of my illness. I discuss strategies for overcoming it that worked for me.

I also maintain contact after clients have left treatment . . . if a client emails or calls I respond; I also occasionally reach out to them to see how they are doing. It is possible to maintain boundaries: it is the nature of the relationship that is important. They always know they are clients or former clients, not friends.. . take the client who called after 7 years of recovery who was in town with her new baby and wanted to see me. Should I say 'Make an appointment"? For me my humanness overrides that silly thought and I agree to a cup of coffee together. . .

The key, for me, is that although there are guidelines, at some point we also have to trust the things that we know. . . . I do my best to keep true to my profession and my humanness at the same time."

Thanks Carolyn, for your wise and thoughtful response. I'm looking forward to hearing from other colleagues. Until next time, blessings! Gail Hall

Professional Boundaries

I had lunch recently with a couple of colleagues who do not work primarily with eating disorders. We were discussing the issue of whether it's appropriate to keep in contact with ex-patients. Both of my colleagues seemed quite clear in their position, that it's never appropriate: "once a patient, always a patient"; "our ethical guidelines indicate we don't create dual relationships". We also discussed the pros and cons of attending events, such as graduations or weddings, on the invitation of a patient. Again they were both of the opinion this would not be acceptable. I shared with them that my experience as a therapist has been quite different. I have, in fact, attended events when invited by patients. I do, in fact, keep in contact with some of my patients, at their initiative: although I have also contacted patients to encourage them to participate in a survey, or to invite them to a special event involving Eating Disorders Awareness Week. A few of my patients have gone on to become therapists or dietitians, and we have even allowed one young woman to shadow the dietitian at our practice.

My style as a therapist has always been to be somewhat accessible about my own life. I share from my own experiences: although I have never had an eating disorder, I have had the struggle with self esteem and body dissatisfaction that is common to most women. I don't mind talking about what's "normal" during adolescence, or my experiences as a professional juggling career and family, or ideas about child raising that worked for me. I believe one of the most powerful avenues for healing is the modeling we bring to young women who are confused and overwhelmed with their life choices. In fact, whether we acknowledge it or not, our behavior is being watched closely. I see no harm in allowing questions and opening ourselves up to mentoring.

NEDA is also a unique professional organization in that families and sufferers are invited to attend our national conference. Many professionals in this field have themselves recovered and appear to draw from their recovery when helping others. We stand shoulder to shoulder with families and sufferers as we work to bring change to our culture. Involvement with NEDA has likely also encouraged my thinking in this regard. I know I've been "changed for the better" as a result.

I'd love to hear from other professionals about this issue. Your thoughts? Until next time, Gail

A follow-up question . . .

I received the following comment from Geri in response to my most recent post:
"This was my first year at NEDA, and I too was impressed by how accessible professionals were and what a compassionate, helpful environment it was. I met a woman who had brought her anorexic, adult daughter with her, in the hopes of finding her help. I was struck by how upbeat and positive the girl was after speaking to several treatment professionals. It really goes to show that recovery is all about hope opening a door to a positive chapter of life. Do you find that most people who seek help from you are hopeful, or feel wrangled into treatment by parents or friends?"

Actually my clients come into my office in all stages of readiness for recovery. Some are still in deep denial; some are angry and resentful because they did not come to treatment on their own. Many are ambivalent or conflicted about making changes; a few are completely ready to leave the eating disorder behind; and ALL are frightened. But I really believe that even the most angry or ambivalent client has a part of herself that wants to recover. It's my job as a therapist to search for and connect with that part; to strengthen resolve; and to instill hope. Recovery is never easy, and it can take significant time, energy, and resources. But it IS possible!! Until next time, Gail

NEDA - Still Fabulous After All These Years

I'm on my way home from the annual National Eating Disorders Association conference. I'm proud to say that I've been involved with NEDA since it was EDAP (Eating Disorders Awareness and Prevention) and have attended all but one of their conferences since 1986. NEDA has remained true to its roots in that it is an organization dedicated to awareness and advocacy efforts. At the same time it manages to put on one of finest conferences for professionals in the field, where the latest and greatest information on eating disorders treatments is available. One of the things I've always appreciated most about this conference is the accessibility of the presenters. I can walk up to some of the biggest names in the field and have my questions answered while being greeted as an old friend. But what has set NEDA apart from other organizations is the welcome it has extended to family members, friends, and eating disorders sufferers; and we have all been made richer for it . This morning's panel presentation by family members sharing their trials, joys, and ultimate hope for recovery was one of the most inspirational I have ever heard. Finally, NEDA continues to inspire and energize us towards a world where eating disorders no longer exist. I'm going home with a renewed appreciation for what we will collectively be able to accomplish, and I've been energized to continue the fight. Until next time, Gail

Especially for Parents

I just received my copy of The Parent's Guide to Eating Disorders by Marcia Herrin and Nancy Matsumoto. Although I haven't had time to digest it completely, my initial quick read suggests a wealth of important information for families and the therapists who are trying to help them. It also appears to be appropriate for parents of both young children and teenagers. There are three chapters devoted entirely to discussion of the Maudsley method of treatment for eating disorders, a family based treatment which has had amazing success; and this author's adaptation of that method, Parent Assisted Meals and Snacks (PAMS). There is a very helpful, non judgmental chapter on assessing the parents' relationship to food, their own body image, and how that can impact their children. I intend to use this book as a guide as I continue treatment with my youngest patient, age 7. I will also recommend it to all parents who are interested in preventing eating disorders and developing healthy body image in their children. Until next time, Gail

Kudos to Marion Bartoli & Father

The U.S. Open Tennis tournament has just drawn to a close, and almost everyone knows that Justine Henin and Roger Federer continue their dominance of the women's and men's fields, advancing as champions, both in straight sets. But I want to tell you about a lesser known player, her unorthodox style, and her father's unique coaching methods. Unless you are a pretty avid tennis fan you may not have heard of her.

Marion Bartoli is a 22 year old from France who blazed into focus by appearing in this year's Wimbledon final. At the U.S. Open she lost in the 4th round to American Serena Williams. She uses both hands on her forehand and her backhand; she serves from an unusual tip-toed stance; and apparently her father/coach has her practice service accuracy by casting with a fishing rod. It's rumored that he's a bit of a tyrant with his protege; but as John McEnroe noted, his unusual methods may come into vogue now that she is achieving some success.

But it was not her tennis training which caught my attention. Rather it was the discussion re: her weight, and the questions around her level of fitness, which the commentators tossed around during her matches. There were subtle (and outright) suggestions that she'd be better if she just took off a few pounds . . . As therapists we know full well the power of those words. Just such a suggestion from a coach, trainer, or parent has launched many a young woman into a diet which spiraled into an eating disorder.

Tracy Austin set the record straight. She noted that Marion's father engaged the services of a trainer for her this year; but when she changed her training regimen and lost weight he felt she became weaker on the tennis court; so he wisely stopped the process and encouraged her to return to her previous (healthy) weight. What a concept: GAINING weight in order to improve athletic performance. I wish all coaches - and fathers - understood this principle. Until next time, Gail

It's Back to School Time!

Earlier this summer I wrote about the summer months as an opportunity to catch up with former patients who are back in the area, dropping in for "wellness checks". Now that fall is around the corner most of my patients are beginning a transition back to school, with all of the stresses and opportunities this change brings. Since many eating disorder sufferers are prone to anxiety and risk-avoidant, they often experience significant anticipatory anxiety as they wonder: will I like my new teacher? Can I handle the work load? Will I have any friends? What if I don't keep my perfect 4.0 record? Will I make the cross country team? How different is high school from elementary school? How can I keep up in marching band when I missed band camp? And many, if not most, of these fears, can be translated into food, fat, and body phobias. Therefore some of the important work of therapy at this time involves decoding the fat fears and translating the underlying fears into words. As we all know, fears translated and expressed become much less powerful; and then the focus can turn toward problem solving skills.

It's also true that school can present some real obstacles. Often we've had to be creative with a client's meal plan when she has to leave for school by 7 a.m. and has been assigned to "first lunch" at 10:50. Frequently teachers prohibit eating during classes which calls for some advocacy to allow time for snacks. And although we work very hard to teach our clients not to value themselves based solely on their appearance, an ill-timed comment from a peer can undo a great deal of progress in this area.

On the other hand, a return to school can be of positive benefit for some of my patients. Sometimes there is comfort in the return to the routine that summer cannot always provide. Other times the incentive of returning to participation on the fall sports team can provide motivation to gain and maintain weight. For some college-aged individuals coming back to campus represents a return to their most supportive environment.

I'm certain all of you who work in the field are aware of the potential benefits and pitfalls of the return to school season. Please write and share your thoughts. Until next time, Gail

Update on "First do no Harm"

I've received a few comments and suggestions re: my last post. Meanwhile, I've continued to see this child and her family. They are scheduled to see one of my staff dietitians next week, then we hope to meet together to decide on next steps. I will continue to post as our process unfolds.

Your advice to date has been helpful; no one suggests that leaving out the child and focusing exclusively on her parents makes sense. All are in agreement that parents are a vital part of the process; but at least one professional who has worked with young children is encouraging me to see her alone occasionally as a way to hear her thoughts and feelings without her parents present. Parents and I have already agreed that a more consistent schedule and a plan to approach mealtimes will be helpful; it seems too often now eating gets delayed, or squeezed in between the pick up from day care and after work errands. Parents also tend to approach the struggle around eating in slightly different ways, and I've encouraged them to use the strengths of each approach to find a more consistent model. We also see that their daughter has some nutrition myths which will need to be challenged by more accurate information.

I've been reminded that young children can sometimes develop medical complications, and therefore need hospitalization, more quickly than our older patients. I plan to have the dietitian monitor weight here, and have the pediatrician monitor other vital signs as needed so that we avoid the need for emergency intervention. It's still my hope to be able to help this family without inpatient treatment.

I will welcome ongoing comments from other professionals; and from parents who've had a young child in treatment. What was most helpful to you? Until next time, Gail