Family involvement is an important part of treatment in the eating disorder programs at Rogers Memorial Hospital and it offers an important opportunity for families to learn these benefits together and leave with a common vision. Thielke encourages the families she works with to venture out and follow the acronym “RECIPE” to begin that road to a more positive dining experience:

• R is for “Repair”- Take time to first repair your own thoughts and habits about food, nutrition, health, and weight. Remember the “practice what you preach” approach; did you eat breakfast today?
• E is for “Example”- Children learn by example, so eat your vegetables. It can take more than 10 times for a child to see a food before they accept it. Give you and your family permission to enjoy food. Don’t label foods as “good” or “bad.”
• C is for “Communication”- Communicate often about food and about life. The dinner table is a great place and time to turn off the TV and talk to each other.
• I is for “Internal”- Focus on the internal body, not the outside (weight, shape, etc). Focus on the internal values (compassion, kindness, and strengths). Ask how family members are doing. Don’t talk about disordered eating, behaviors, food, nutrition, or weight and exercise at the dinner table with those struggling with an eating disorder.
• P is for “Physical Activity”- Make physical activity fun and make it a family affair. It’s all about clearing the mind as well as needed for overall health. Try badminton, basketball, walking the dog. Or Thielke’s favorite: Grow a garden together as a family.
• E is for “Encouraging Healthy Habits”- Increase consumption of fruits, vegetables, and whole grains. Have children grocery shop with you. Include all family members when planning meals and cooking. Increase water consumption, decrease soda and juice consumption to ensure a more nutrient dense meal plan. Don’t use foods as rewards.

According to Thielke, following this “RECIPE” in any family can assist in an overhaul for everyone nutritionally and emotionally. Family members find that eating meals together can provide a time to actually listen to one another, a time to bond and create a healthier nutrient intake throughout the week.
By including the whole family in menu planning it gives them a sense of belonging and ownership and younger members may be more willing to try new foods, even making suggestions for fresh vegetables or requesting new favorites.

“When I was a girl, I had to ask to be excused before I could leave the evening dining table. At the time I didn’t realize that having meals with my family provided an atmosphere that would increase my self-esteem and teach me appropriate behaviors and manners,” Thielke said.

“Children learn from example. This can lead to guilty and shameful feelings for parents who are struggling with an eating disorder. It can also be an encouragement to reach the goals of recovery. Whether someone is struggling with an eating disorder or not, providing the example of good and positive behaviors surrounding food will contribute to an overall healthy atmosphere.”

“There have even been studies that show family meals can lower the incidence of depression. There are many advantages to organizing meals throughout the week, so make it a priority to start getting together at least four times a week,” she said. “As one of my current patients phrased it: ‘Dining room tables are not just for centerpieces’.”

 Thought challenging is a supplemental technique used at Rogers Memorial Hospital in the treatment of residents who have co-occurring anxiety and eating disorders in the special dual diagnosis unit. This technique is used to lower the anxiety-producing thoughts which accompany their eating disordered behaviors. Generally, errors in thinking fall into two categories, overestimation and catastrophizing.

A probability overestimation error is when someone overestimates the likelihood of a bad event happening. A catastrophizing error is when someone blows out of proportion, magnifies, or catastrophizes how bad fairly likely events really are. Thought challenging addresses these errors.

Thought challenging has three steps:

• Identifying fears which keep them from engaging in anxiety provoking situations
• Identifying factual evidence which they believe supports the likelihood of their fears occurring, and
• Systematically examining the evidence identified to determine whether it truly supports the occurrence of feared consequences.

Learning to lower anxiety levels

Throughout their stay, residents cite their individual experiences with anxiety and construct their own arguments against feared consequences. The result is individualized and personally believable arguments they can use against their internal anxiety.

Members of Rogers Memorial Hospital’s eating disorders treatment team use thought challenging to target feared foods, binge foods, compulsive exercise, body checking behaviors, body avoidant behaviors, body image dissatisfaction and mealtime ritual behaviors, among other eating disorder symptoms.

Building upon successful experiences

Self-efficacy, or the ability of a person to feel competent and masterful in his or her journey toward the goal of recovery, is an important aspect of relapse prevention. Often this mastery is built upon previous experiences and examples of skillful responses to triggers and anxiety.

As a result of thought challenging, patients are able to feel more confident in their ability to encounter stressful situations and manage their thoughts and urges in a skillful and effective manner.

I had the honor of being a part of the NORMAL in Schools gala in February. It was a new experience for me, as I have not had the chance to speak directly with members of our community about eating disorders and art therapy.

The vast majority of the work I do as an art therapist at The Eating Disorder Center involves working on body image as well as challenging “eating disorder thoughts.” The art display offered an opportunity for gala attendees to get a better understanding about the benefits of art therapy for our patients.

Discovering art therapy

I was asked a lot of interesting questions and heard excellent feedback about the artwork displayed. I answered questions from people who were first learning about art therapy to those who wondered how eating disorders develop. I was pleased to see the level of interest shown by attendees who wanted to learn more about art therapy and eating disorders.

On the flip side, I was astonished by the existing need to better educate the general public about mental health disorders, treatment effectiveness and the types of treatment available. The main question I heard was “How does art therapy help?” As I explained that evening, the answer varies depending on the individual being treated.

Sharing the value of art therapy

Further explanations of the images on display helped gala attendees understand how creating an idea in art form gives individuals a way to see how their eating disorder influences their life. One piece contained an image of an egg resting on a nest. The nest, as protector, was nurturing the egg. When relating it to the eating disorder, it represented how the individual feels protected and nurtured by the eating disorder.

Some patients use artwork as a means to separate themselves from their eating disorder. The artwork is viewed as a separate object, representing the eating disorder, apart from themselves.

Many people were amazed by the resulting impact of the image, as I heard “Wow. That is a powerful image.”

Building awareness

Meeting and talking with so many people who are helping those struggling with eating disorders as well as those who struggle themselves was very moving. A personal highlight was meeting former Miss America Kirsten Haglund and seeing her perform a portion of the musical “Normal.”

My experiences at the gala continue to affect me as I reflect on our community’s enthusiasm to help fight a disorder that affects so many. It is encouraging to see the number of people who are willing to support each other.

Learning to lower anxiety levels increases success in recovery
From their initial assessment through the end of their stay, Rogers Memorial Hospital’s patients identify situations related to their eating and anxiety disorders that provoke intense levels of anxiety and assign an anxiety rating (on a 0-7 scale) to each of these situations. The higher the anxiety rating, the more difficult it is for these patients to encounter that situation.

Exposure in a prolonged and repetitive manner
Treatment teams at Rogers Memorial approach anxiety-provoking situations gradually. When patients are exposed to challenging yet manageable levels of anxiety (denoted by a rating of 3 on the 7-point scale), they are better equipped to resist engaging in harmful eating disorder behaviors such as restricting, bingeing, purging, and compensatory exercise.

Some patients fear certain foods, like pizza or ice cream, and anticipate unrealistic weight gain as a response to the consumption of their feared foods. The treatment team finds ways to build an experience of gradual exposure. Depending on an individual’s level of anxiety, the food may only be present in the room at first, but later is held or on the table.

Ultimately, a patient learns to overcome their fear and incorporate their feared foods into their individualized meal plans using a modified version of the exchange system similar to the one developed by the American Dietetic Association.

Anxiety levels decrease
Rogers Memorial’s patients get used to, or habituate to, their anxiety when they are exposed to that situation in a repetitive manner. Their anxiety levels decrease over time, and they are able to see that what they feared would occur in a given situation did not happen.

This gradual exposure approach is called Exposure and Ritual Prevention Therapy (ERP), which is a specific type of Cognitive-Behavioral Therapy (CBT). ERP has been shown to be the most effective in treating Obsessive-Compulsive Disorder and other anxiety disorders. This therapy is used extensively at Rogers Memorial because it allows patients the opportunity to confront their anxiety at a manageable pace, thereby increasing their self-confidence to continue their treatment.

Inarguably, self-efficacy is one of the best things patients can take with them when they leave treatment and continue with their aftercare.

 Being in a safe, functioning environment where the expectation is to share your feelings and to get your needs met by asking, brings negative thought patterns to the forefront where they can be addressed.

Some examples of these negative thought patterns:

• I don’t deserve to get what I want or need.
• It doesn’t really make any difference; I really don’t care.
• I should be willing to sacrifice my own needs for others.
• Being emotional means being out of control.
• Letting others know that I am feeling bad is weakness.
• I don’t want to hurt anyone.

Hearing a peer in group therapy share thoughts similar to one’s own pattern of thinking allows the individual in treatment to see how common disordered thought patterns can be separate from their own sense of self. For example, a group member may see the personal qualities of a peer and see how that peer’s perception of self is affected by eating disorder thoughts patterns.

This awareness, along with advice offered to peers, often leads the individual to conclude, “I need to be willing to follow my own good advice.”

Healthy boundaries around emotional and behavioral responsibility are developed. These new experiences support the individual’s ability to change their interpersonal patterns and develop new ways of interacting with others.

Some examples of changing thought patterns:

• My wants and needs are important.
• I really do care, about myself and others.
• When I take care of myself, I have more to give to others.
• Sharing emotions is part of developing intimacy in relationships.
• Letting others know how I am feeling is investing trust in our relationship.
• Being a compassionate person means I am sensitive to how others are feeling but I am not responsible for how they feel.

Many new participants who were initially anxious about group therapy find a sense of safety and support within this environment. It is a place where secret thoughts and behaviors are shared and a sense of understanding and acceptance is discovered. Not only is the diagnosis of illness shared, but the need and the ability to change thoughts and behaviors.

Many within the first few days of treatment in the group therapy model will say, “It is such a relief to know that I am not alone.”

A recent outing revealed the need for strong support in an environment that is meant to be enjoyable and relaxing.

Our treatment team had selected a chain restaurant with large food portions to help patients work through their anxiety about food and with learning appropriate portions.

When our waitress introduced herself and the restaurant she boldly proclaimed that each entrée contained “A pound and a half of pasta!” You can imagine the anxious and guilt-driven thoughts that ensued in our already apprehensive group.

Next, one of our patients asked if the restaurant had low-fat dressing for her house salad that she was going to have prior to her entrée. (We do encourage patients to order regular dressings to challenge the diet mentality, but ultimately patients make these decisions on their own).

Our waitress had no idea where we were from or that our group included several people with eating disorders.

The waitress’s response was, “Oh no, honey. There is nothing low fat in this place!” Her comment demonstrates the challenges our patients routinely face and why it’s necessary for us to provide them with these supported activities.

This encounter reinforced precisely why we value the effectiveness and importance of these meal outings to help our patients with the recovery process and learn how to manage the effects of an off-hand comment.

And, that night, that’s exactly what we did. Our group was able to process these experiences and successfully get through the meal, including dessert.

Did you know that football and rowing also have weight restrictions? Youth football leagues typically put caps on weights for entering the league and for certain positions. For instance, in certain leagues you must weigh 80 pounds to carry the football, and you cannot carry the ball if you weight over 100 pounds. Football and other sports typically have weight limits for safety reasons, however, in certain situations these types of weight restrictions can be detrimental to children’s health.

This is particularly true for kids who may be pursuing a certain position within a sport, or become obsessed with reaching a target weight for the sport in order to participate. This ultimately can lead to unhealthy weight loss, poor nutrition, disordered eating habits, and eating disorders.

Kids may restrict their food intake, increase their activity level, and exercise more to reach a desired weight to get a desired position. These behaviors become dangerous when they lead to dehydration, unnatural weight loss, and possibly abnormal body functions including low potassium.

These days our children have vast opportunities to participate in sports, whether it’s through school, local parks or recreations departments, sports leagues or athletic clubs.   There are also multiple levels of sports in which children and teenagers compete including recreational, intramural, league, and even select. This is all in an effort to keep kids active with their peers, within their community, and for their health. What a wonderful thing!

Here’s some advice for moms and dads…

Listen to your kids!  Talk to coaches if you have concerns. Watch your child’s eating, sleeping, and activity patterns. Allow one activity per semester so kids don’t get too overwhelmed.  Remember, health comes first!

What to watch for:

1. Increasing discussion about weight limits in sports. This may come up as a nonchalant topic after a weight check at the doctor’s office, or a health check. Ask questions and get a good understanding of your child’s thought process.
2. Changing habits – changes in eating patterns: eating less, paying close attention to calories or food labels, restricting intake, avoiding certain high fat/carb/calorie foods, restricting/over eating cycle, laxative use, or purging.
3. Obsessing: Frequent weighing of self or obsessions regarding a certain measurement.
4. Over-exercising: your child/teen should not have to exercise much more above and beyond their athletic practice times. If you notice that they are exercising before and/or after their practices, a red flag should go up!

What to do:

1. Talk with your child and get a good idea of what is going on.
2. Call your primary health care provider and schedule an appointment.
3. If you have concerns that your child has an eating disorder, call Rogers Memorial Hospital at 800-767-4411. We can provide free telephone screenings or additional information about our specialized programs. We also offer an online screening.