Episode 232: This week's guest on the podcast is Dr. Lauren Muhlheim. We discuss Cognitive Behavioural Therapy (CBT) for Eating Disorders, Family Based Therapy (FBT) for families with adolescents in recovery and Avoidant Restrictive Food Intake Disorder (ARFID).
Dr. Lauren Muhlheim, is a psychologist, certified eating disorder specialist (CEDS), and IAEDP (International Association of Eating Disorder Professionals) – approved supervisor who provides evidence-based treatment for eating disorders in the outpatient setting. She works with people of all ages and all eating disorders including anorexia nervosa, bulimia nervosa, binge eating disorder (BED), Avoidant Restrictive Food Intake Disorder (ARFID), Orthorexia, Muscle Dysmorphia and Male Eating Disorders.
She provides cognitive-behavioural therapy (CBT) for adults and family-based treatment (FBT) for adolescents and adheres to Health at Every Size® principles. She is certified in FBT by the Training Institute for Child and Adolescent Eating Disorders.
Dr. Muhlheim is the author of When Your Teen Has an Eating Disorder: Practical Strategies to Help Your Teen Overcome Anorexia, Bulimia, and Binge Eating. This book is an FBT-based book for parents who are helping adolescents with eating disorders.
Dr. Muhlheim is active in several professional organizations. She is the Eating Disorders Expert for Verywell (formerly About.com) and is Clinical Director of the Eating Disorder Information website, Mirror-Mirror Eating Disorders. She presents nationally to parents, professionals, and trainees. She is active on social media and in eating disorder advocacy efforts. Find her online at EatingDisorderTherapyLA.com
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Chris Sandel: Welcome to Episode 232 of Real Health Radio. You can find the show notes and the links talked about as part of this episode at www.seven-health.com/232.
Hey, everyone. Welcome back to another episode of Real Health Radio. I’m your host, Chris Sandel. I’m a nutritionist that specialises in recovery from disordered eating and eating disorders or really just helping anyone who has a messy relationship with food and body and exercise.
This week, the show is a guest episode, and my guest today is Lauren Muhlheim. Lauren is a psychologist, a certified eating disorder specialist, and an International Association of Eating Disorder Professionals approved supervisor who provides evidence-based treatment for eating disorders in the outpatient setting. She works with people of all ages and all eating disorders, including anorexia, bulimia, binge eating disorder, avoidant-restrictive food intake disorder, orthorexia, muscle dysmorphia, and male eating disorders.
She provides cognitive behavioural therapy (CBT) for adults and family-based therapy (FBT) for adolescents and adheres to Health at Every Size principles. She is certified in FBT by the Training Institute for Child and Adolescent Eating Disorders. She is also the author of When Your Teen Has an Eating disorder: Practical Strategies to Help Your Teen Overcome Anorexia, Bulimia, and Binge Eating. This book is an FBT-based book for parents who are helping adolescents with eating disorders.
Dr Muhlheim is active in several professional organisations. She is the eating disorder expert for the website Verywell, which was formerly About.com, and is the clinical director of the eating disorder information website Mirror-Mirror Eating Disorders. She presents nationally to parents, professionals, and trainees, and she is active on social media and in eating disorder advocacy efforts. You can find her at www.eatingdisordertherapyla.com.
I’ve been aware of Lauren for some time now. She is rather prolific in her writing about eating disorders for the website Verywell.com, and I’ve read many of her articles there. In fact, when I was putting together the recent episode I did on brain changes that occur because of restriction, one of her articles was the first one that came up, and it pointed me towards a number of papers that I then referenced in that episode.
As part of this discussion with Lauren, there were three main topics that we covered in a fair amount of detail. The first is cognitive behavioural therapy, or CBT, for eating disorders. We talk about what it is, some of the foundational ideas, and how it is used in practice. As Lauren points out, the name can be somewhat misleading because the word ‘cognitive’ is in its title and it’s misunderstood that this means talking about beliefs and challenging beliefs with different thoughts, when in fact it’s mostly about behaviours and taking action. I’d wanted to cover CBT on the show for a while now because I find it so helpful with clients, so it was great to be able to have this discussion with Lauren.
We talk about family-based therapy, or FBT, and what it is, how it works, how Lauren uses it in her practice. Finally, we talk about avoidant-restrictive food intake disorder, or ARFID. This is a lesser known eating disorder that Lauren is increasingly working on in her practice. She describes what it is, the three different types of ARFID, and how each of them is treated.
This is an incredibly practical episode, and there’s lots of ideas that I believe can be really helpful. So here is my conversation with Lauren Muhlheim.
Hey, Lauren. Welcome to Real Health Radio. Thanks for chatting with me today.
Lauren Muhlheim: Thanks for having me.
Chris Sandel: I’m a big fan of your work. I’ve read many articles that you’ve written, and I’ve heard you on a number of podcasts. You’re someone who’s had a long career and a diverse career, working in many different areas and different locations and countries, and you have a real wealth of experience with eating disorders, again, across a real wide range. I think this conversation is really exploring many topics and having you be able to share your expertise and knowhow with the listeners and hopefully touching on some areas that I haven’t explored before on the podcast.
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Just to start with, do you want to give listeners a bit of background on yourself? Who you are, what you do, what training you’ve done, that kind of thing?
Lauren Muhlheim: I’m a psychologist with a group practice in Los Angeles, where we specialise in eating disorders. I’m also licensed in New York and Indiana, and I have about seven employees. I started my eating disorder training when I was in grad school at Rutgers and I had the opportunity to train under Terry Wilson, who was one of the co-creators of CBT for bulimia before it was CBT-E. He was Fairburn’s main collaborator. So I got really good training back in the 1990s in CBT, and that was really when I fell in love with eating disorder work.
After grad school I did a number of different things before I got back into eating disorders, and I actually got back into eating disorders when I was living and working in Shanghai, China. I was there for my husband’s job, and when I said I had eating disorder experience in the expat counselling community, I immediately started to be referred patients with eating disorders. Most of my training had been with adults with bulimia, and here I was getting adolescents with anorexia.
So I very quickly had to seek more training, and I actually flew to Stanford to do an FBT training with the official training institute. After that, I fell in love with FBT and started to really learn and study FBT and treat adolescents using that model. Shortly after that, I moved back to Los Angeles and set up my group practice and got certified in FBT. Wrote a book for parents based on FBT and got also very involved in Health at Every Size as a philosophy, so I’ve really done a lot of training and self-development in that area.
Then I guess my most recent interest is ARFID because I had a behavioural background and had known Jenny Thomas. She really encouraged me to start seeing ARFID patients. I did a lot of training with her, so now the ARFID area of my practice has also grown. I see children and adults with all eating disorders, all genders, and the three main things I do are CBT infused with Health at Every Size for adults, FBT for adolescents, and CBT-AR for adolescents and adults with ARFID.
Chris Sandel: Nice. I want to go back through each of those in detail. For listeners, if you’re like, “I don’t know what CBT or FBT or ARFID stands for”, we will go through each of those.
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Just in terms of getting more background on you, what was food like growing up in your household? How was food when you were a kid?
Lauren Muhlheim: Food in my house was normal until I hit puberty, and then the adults in my life panicked about my weight and I started to be encouraged to diet. I went through a lot of dieting from about 13 to 18 while everyone was worried about my weight. That was a difficult time.
Chris Sandel: Were you doing that dieting on your own? Were you doing it with friends?
Lauren Muhlheim: Originally I think I did it with my mother, and then after that I was sent to people to fix my weight.
Chris Sandel: And when you say sent to people, what was being recommended at that point for you?
Lauren Muhlheim: Restriction. I was sent to Diet Center, which was an old diet company. It was very sad food. I remember in high school going out with my friends, and they would buy pizza and I would have my little chicken breast. It was very depriving. I think I did that, I did Weightwatchers. I was sent to an individual nutritionist, sent to the gym. Everyone in my family was very focused on my weight and wanted me to be thinner.
Chris Sandel: What did you do to come out the other side of that? You said that was up until a certain age; how did that change for you?
Lauren Muhlheim: I was in therapy in college, and that really helped me to break the diet cycle and to stop restricting. And that really helped. I was lucky and privileged to be able to access therapy, and that helped me to get past the dieting. I never went back.
Chris Sandel: Wow. That’s quite a big change. What was the advice or what was the thing that started to really make that change for you? I know you said you were in therapy, but what was the model that they were using? Or what was the thing that made the difference?
Lauren Muhlheim: I remember the most important thing at the time was the advice that I should have a sandwich for lunch and not a salad, which was what I had been taught in my family. And the permission for starches seemed to break this dieting and then rebound eating from depriving myself and then having unplanned eating later in the day.
Chris Sandel: And do you remember that? Was that a difficult transition, or was it like “As soon as someone gave me that permission, it locked in and I felt I could do this”?
Lauren Muhlheim: Yeah, I remember it being like a “Wow, it was that easy?” [laughs] I didn’t have an eating disorder, clearly. I had some disordered eating, but it was pretty quickly righted by just eating more regularly.
Chris Sandel: Did that then come as a bit of a surprise later on when you did start working with eating disorders in terms of reflecting on your own experience, thinking “Oh, I thought this was going to be more straight forward. I got that information pretty easily and was able to course-correct”?
Lauren Muhlheim: I don’t remember even tying, when I first learned CBT, tying it so much to my own experience at first. I remember just seeing with the patients I was helping that a similar thing happened – that when we broke the dieting, the binge eating stopped in many cases pretty quickly. So I think I was really drawn to the cognitive-behavioural therapy model. At some point I must’ve related to it as well. [laughs] I don’t remember that.
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Chris Sandel: When you went off to study as a psychologist, what did you think you would be working in? What was the pull or what was the interest for you with psychology?
Lauren Muhlheim: I don’t remember what I originally thought I was going to do, but I was in the psychodynamic track at my school and was very into that treatment. Then I had a friend who was a little ahead of me who was working with Terry Wilson and had really found it amazing training. Because I was in this programme, I actually had to beg him to let me train with him. [laughs] Eventually he did, and that training really swayed me in so many ways. I never thought I would like doing cognitive-behavioural therapy, and I really just found it so effective.
I don’t even know if I decided that that was what I wanted to do at that point; I just wanted to train with him.
Chris Sandel: What was it about him that was so alluring or made you think “I need to be here”?
Lauren Muhlheim: I think in retrospect, it was the only clinical research going on in the grad programme. I mean, there were some other things that had no interest to me, and this was very clinical research. So I think that’s what drew me to it – that he was doing clinical trials of treatments. It felt very practical to me.
Chris Sandel: Did you feel like you might become a researcher and that would be your full-time thing? Or was there always the feeling of “I like doing the patient work and I want to be more working as a clinical psychologist”?
Lauren Muhlheim: It was more around the clinical work.
Chris Sandel: You mentioned there about you were on the psychoanalytic track and then you changed over. For people who don’t understand or don’t know the difference between those two, how would you conceptualise what a psychoanalytic way of therapy is versus the cognitive-behavioural therapy way of therapy?
Lauren Muhlheim: Psychoanalytic or psychodynamic therapy focuses on there being some kind of underlying conflict that needs to be solved, and it’s using the therapeutic relationship to uncover what has gone on in someone’s past, in relationships, and looking in someone’s history to solve the problems in the present.
Cognitive-behavioural therapy is more focused in the here and now, and it focuses on looking at current behaviours and thoughts and looking and analysing those and making changes in the present to change thoughts and behaviours and feelings. It’s much more focused on what’s maintaining a problem than what initially caused it.
Chris Sandel: For you, now as a practitioner, is it purely CBT? Or do you see some benefit in starting to explore what someone’s history is and those kind of factors? I mean, even if it’s not about helping with therapy, but more about relationship building – do you go back through those kind of things?
Lauren Muhlheim: I think in practice, everyone is a little bit eclectic. I think my primary approach is cognitive-behavioural therapy because, again, the impact of working with Terry Wilson made a big impact on my way of thinking in that the research in support of behavioural treatments for eating disorders shows that they’re so important in interrupting especially dangerous behaviours, in the case of bulimia.
So I always start with cognitive-behavioural therapy, but it doesn’t mean that my psychodynamic training doesn’t inform me in some way and that I don’t appreciate that people have a history and have been impacted by relationships in their past. Sometimes I will step back and think about people in more psychodynamic terms. But the work is still primarily cognitive-behavioural.
Chris Sandel: I would agree; a lot of the work that I do is in a similar vein, where it’s CBT or acceptance and commitment therapy or ways of “Let’s look at the current situation and how to make changes moving forward.” But I also do think it’s helpful to explore what it was like when you were growing up or what was the impact like in terms of your mother’s dieting or whatever, just so someone can have a better understanding of who they are and how they became to be – even if, as you said, it doesn’t necessarily change the present and the thing that someone has to do.
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As I said at the start, I haven’t really explored cognitive-behavioural therapy or CBT on the podcast in any detail, so I think it would be useful to spend a bit of time having a conversation around it. What would be the best way of trying to do this? Would it be useful to maybe demonstrate CBT and how a CBT intervention could work if we picked a particular thing, like a fear of a particular food or a fear of weight gain or something like that? Just to give someone a sense of what CBT looks like when it’s being used.
Lauren Muhlheim: I think we should start with looking at the cognitive model. The key point of CBT is that it looks at the dieting or restriction as causing binge eating, and then there may or may not be compensatory behaviours other than restriction. It’s a cycle, and we start by drawing it out for patients and looking at how dieting maintains binge eating. Most people come to therapy and blame themselves and say, “I have no willpower. I can’t maintain my diet.”
So the key part of cognitive behavioural therapy is educating people on this model and helping them to see that it’s not that they have poor willpower, but that their bodies are working perfectly because our bodies were not meant to be deprived of food, which is one of our five basic needs.
So that’s the core element, I think. And one of the reasons why I think cognitive behavioural therapy fits in so nicely with Health At Every Size and intuitive eating, because it really focuses on making sure that people are eating enough. That doesn’t mean that there isn’t weight stigma in the original CBT manual, which is another pet project of mine. [laughs] I’ve been looking at trying to address some of the weight bias in CBT. I think some people want to throw CBT out because there is some weight stigma embedded I the treatment manuals, but I think at its core, the cognitive behavioural therapy that’s just looking at thoughts, behaviours, and feelings that are maintaining a problem is weight neutral, and the way it’s been applied in some cases to bulimia and binge eating, weight stigma has entered. It doesn’t have to be there, because at its core, it’s this model of making sure that people are eating enough.
I think one of the things that people misunderstand about cognitive behavioural therapy, at least as I’ve seen other clinicians apply it, is they think it’s mostly a cognitive model and that we’re arguing people out of their food roles. I think that’s one of the misunderstanding of cognitive behavioural therapy. It’s really primarily a behavioural treatment, and it’s mostly about changing behaviours and changing thoughts by changing behaviours. So rather than disputing whether it’s bad to eat hamburgers, it’s more about getting the person to eat a hamburger and then seeing what happens.
Chris Sandel: In terms of your original statement of getting someone to understand that it’s the restriction that’s leading to this – even if someone doesn’t accept CBT, you’re just describing pure biology. Like, this is what happens when you underfeed a human being, and this is what happens when you overexercise a human being. There is energy that needs to be used for the body to function properly, and when that is restricted, there is a chain of events that happen – and we have it well-documented that this is what happens.
So I think it’s really helpful to put someone in touch with the reality of the situation of like, this is pure biology that is driving you in this way. It’s not, as you say, about willpower or you being broken or anything; it’s like, this is your body doing what it should be doing.
Lauren Muhlheim: Exactly.
Chris Sandel: I also agree with you in that second point about the word ‘cognitive’ and getting in the way of people thinking about what it really is. As I said before, I really quite like acceptance and commitment therapy, and from my understanding, that’s somewhat of an offshoot of CBT. Am I correct in that?
Lauren Muhlheim: Correct.
Chris Sandel: And a big part of that is the action-taking. It’s not just, how do we work everything out in theory? It’s about the taking action and about the fact that by taking action, that’s how you prove yourself wrong or discover that you could do that thing that you didn’t think you would be able to do. I often have this conversation with clients: confidence turns up after the event, not before it.
Lauren Muhlheim: Yeah, same thing. I say if you’re afraid of doing something and you’re waiting to not be afraid of it to do it, that’s never going to happen.
Chris Sandel: Exactly. It’s by saying, “Hey, this feels uncomfortable. I feel unsure” and then you do it and realise that you could do it, and then you do that a number of times, and with enough practice it then becomes normal and it becomes okay. Or you see that it is still difficult, but I’m able to do it.
Lauren Muhlheim: Exactly.
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Chris Sandel: With all of that as a primer, would it still be worth going through a particular issue and showing how CBT would work?
Lauren Muhlheim: Yeah. One of the other things that’s a core element of CBT is keeping records. Whether someone has depression or an eating disorder, we usually ask people to keep track of something. If osmeone’s depressed, we might have them track their mood and their activities, because then we’re using that information to help them make behavioural changes.
With eating disorders, we ask people to track their food intake. This is not in a diet-y way, and it’s not meant to help people restrict or count calories, but it’s for the purposes of really making sure that they’re eating enough. One of the things when we have breakthrough binges after someone has instituted some regular eating – let’s say there’s a binge in the afternoon, and then we might work with them and trace back and say, “What did you eat earlier in that day? Did you have breakfast? Did you have lunch? Did you have your snack?” and looking for where there are times where they maybe missed a meal or snack or they restricted or they didn’t eat enough.
Or maybe instead of having their snack, they went to the supermarket and bought a bunch of food, and then they came home and they left the food out, and then they reached for it and started eating. So we can do these behaviour chains where we look back and say, “Okay, if this situation were to happen again, is there something you could have done differently?” Looking at, “Could you have had a snack before you went to the supermarket? Maybe you could have put the groceries away when you got home.” So looking at making behaviour chains, behavioural changes to problem-solve for future situations.
It’s about learning skills and thinking through situations and then problem-solving based on where people struggle and helping them to have skills to solve similar situations in the future. I always think of it as developing a toolbox of skills, and as I work with patients and they say, “I’ve got this thing coming up”, I say, “What strategies are you going to use?” So they try to anticipate, “I’m going to the beach and I’m going to be in a bathing suit, and I’m going to be navigating how to eat in front of my friends.” So then we plan ahead and we say, “Based on what we’ve learned, what skills can you use in that situation?”
And they know when they go into different situations, they have to have a plan for it. All along, they’re developing skills to handle different situations around food, around body, and around tolerating anxiety and distress.
Chris Sandel: Nice. A lot of what you talk about there is stuff that I do with clients as well. I used to call it a food log; I now call it an awareness log. It’s like, what time did you go to bed? What time did you wake up? What time are you having your meals? What are you having as part of those meals? What symptoms are you noticing throughout the day? What’s your mood like throughout the day?
The thing I always say is I genuinely don’t care what you eat in terms of a judgment side of things. It’s more like, let’s look at this objectively, and whatever’s working for you, keep doing those things, and whatever’s not working for you, let’s figure out a way of doing something different. Starting to look through that and notice patterns in terms of, “Okay, I notice that every time on the days that I was doing this thing in the morning, in the afternoon there would be this other thing that would happen.” Or “The days that I don’t sleep very well are the days that I had this thing for dinner” or whatever it may be.
But yeah, using that as a way for them to be objective with it and to start noticing some things. I often will use the rubric of “Imagine this was the log that your friend had sent to you and they’re suffering with a thing that’s similar to what you’re going through. What advice would you give for your friend?” Because I think sometimes it’s a lot easier to solve other people’s problems and it’s a lot easier to be objective and say the things that you’re noticing through that when looking at it through that lens.
And the same, if people are having binge episodes, doing an awareness sheet after that and looking at, what’s the chain of events that led up to this? As you say, it’s like, “I missed my snack in the morning” or “I’ve had three days where I’ve been really stressed and I haven’t been eating enough.” 99 times out of 100, it comes back to “You haven’t eaten enough food and that’s how you’ve ended up in this place.” Or “You’ve eaten the regular amount of food that you’re eating, but there’s this additional stress or there was this additional thing on top, so again we’re back in the realm of you haven’t eaten enough food for what your body needs at this point.”
Lauren Muhlheim: Yep, that’s what I spend most of my time telling people: that they’re not eating enough.
And the logs really allow them to see it. I think it’s such a vital tool. And then you can really fine-tune. You find someone who wants to work out in the morning and they can’t figure out when to do breakfast, and then you can run experiments. Like, “Okay, what if you have a snack before your workout and breakfast after? How does that work for you?” They can try it out and report back.
That’s the other key element of CBT – this idea of running behavioural experiments. Again, it’s more behavioural challenges than cognitive disputation. So the person will say, “I can’t do this. I’m afraid to have a sandwich for lunch.” Then you say, “Okay, how about if you run an experiment, and one day you have a sandwich for lunch and one day you have your usual? Let’s see how it goes.” And then we look at the food logs together and they say, “Oh, on the day I had the sandwich for lunch, I didn’t have urges to binge in the afternoon” or something.
So then you’re able to draw it back to their own experience and say not just in theory, people do better when they eat more starches earlier in the day, but they actually see, “In my own experience, when I had a sandwich, I felt much better” or something.
Chris Sandel: Yeah, definitely. And I think that, for me, is so much of the work that I’m doing with clients, like, how do we get you back into your body? How do we get you back to trusting your body and noticing the feedback it’s giving you and being able to accept the feedback it’s giving you? So using the logs can be a way of helping as part of that process.
And the other thing is I always say to clients, I’m not wedded to this. There will be times where actually for a client, keeping a log is worse for them. For whatever reason, it just doesn’t work. I don’t want to then be getting someone to do something that feels like it’s causing more harm than creating a solution. So it’s like, “Okay, let’s step back from that, or maybe we can keep a log in terms of your sleep or your mood, but we don’t put the food in it because at this point, that’s just genuinely not working for you. Maybe we come back to it, maybe we don’t.”
But I definitely feel like over the years of doing this work, I’ve definitely become a lot more open-minded in terms of some things work for some people and some things don’t. It’s like, what is the best solution for this person that I have in front of me? Because the best solution is the thing that someone follows through on or something that gets them to a better place, not some “in theory, this is the best thing, and why aren’t you able to do it?”
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Lauren Muhlheim: Right. In that situation, I also – one of the things – are you familiar with appetite awareness by Craighead?
Chris Sandel: No.
Lauren Muhlheim: That’s actually I think an ACT and DBT based model that also has some weight bias in it, but they have this sheet that’s meant to be an alternative for people who will not do food records. People just keep their hunger and fullness ratings for each meal. They literally just put Xs, and there are these nice sheets. Intuitive eating does 1 to 10; this is actually 1 to 7, which I like because it feels more symmetrical to me to have a single number in the middle. [laughs]
So sometimes I will have patients do that. Just literally each time they eat, put how hungry they are when they start, how full they are when they stop, and they don’t have to put the contents of the food. Sometimes that’s more tolerable for people who don’t want to write down their food.
Chris Sandel: I didn’t know that was what it was called. I use hunger and fullness from intuitive eating with clients, and sometimes that is when they’re writing down the food, and sometimes that is as an alternative. So yeah, that’s something I use.
Also getting them to put down a satisfaction score as well, because I think that’s also a really helpful thing to explore, where it’s not just about getting full; it’s about the enjoyment that you got from that meal, the different taste and texture sensations that make up that meal. That could be getting more into that advanced end of things further on down the line, but getting someone to start to notice those differences again because it brings you back into your body, it gets you back to listening to your body and understanding the feedback it’s giving you.
Lauren Muhlheim: Yeah. I haven’t used satisfaction ratings, but another little tip I just learned from Nancy Zucker – I’m doing her training in FBI ARFID, which is ARFID for little kids – she actually teaches kids to measure their energy rather than hunger and fullness, and I actually thought that was an amazing reframe for some patients who may not be aware of hunger cues so much, but they may be able to notice their energy and feeling. So I’ve started to think about incorporating that a little bit, even with adults.
Chris Sandel: That’s cool. When I’m working with someone, I have a whole list of hunger symptoms that I send over so that they understand that hunger isn’t just a growling stomach or a pit in the stomach, and it can be everything from “I’m feeling a little bit tired, I’m getting more irritable, I’m getting a headache, foggy head, I’m noticing the tips of my fingers are a little bit cold or my nose is a bit cold” – so there’s this big long list that people can look at, so that even in the beginning, if they’re saying, “Hey, I don’t feel hungry”, they then look at the list and think, “I’ve actually got four things on this list. It probably does start to indicate that I am feeling hunger.”
Because if I’m thinking about myself, I’ve gone way, way, way past the point of hunger before my stomach is growling. If I’m using the more obvious, classic forms of hunger, I’m delaying my eating way past the point of where it should be.
Lauren Muhlheim: Yeah, and I like the idea of reframing fullness as having a full energy meter, because fullness is so often pathologized, and the positive reframe of being ‘appropriately fuelled’ may be easier for people to recognise.
Chris Sandel: Yeah. As part of that as well, I look at, what is the longevity of the meal that you just ate? How long does it take you before you are feeling hungry again or your energy’s getting low again or you’re starting to have food thoughts again? So it’s like, oh great, you found a meal that’s now taken you for two hours; before you were only able to do one hour. So again, using it as a positive reframe. Because most clients who come to me are like, “I want to stop the food thoughts.” If I can demonstrate a way that means that you’re having less and less time in the day thinking about it, that’s a positive or a thing they’re wanting to get onboard with.
Lauren Muhlheim: Yep.
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Chris Sandel: One of the things you said earlier that I wanted to come back to because I think it’s important was you talked about, “If we’re going to the beach and I have to eat, what would be some of the things I can do around this?” and the planning of those different things. Part of the planning piece when I’m working with clients is explaining that I expect this to be anxiety-provoking or expect you to feel uncomfortable here, and to set that up so that people don’t go into it thinking, “If I’m doing everything right, I would feel fine here.”
Making this contact with reality of like, “This is what is likely to happen, and that is completely okay, and that also means that you can put on the swimsuit or eat that meal with your friends” or whatever the thing may be, but not having someone think “I will do those things when I don’t have these uncomfortable feelings and that’s my indicator that I’m at the right place to start doing this.”
Lauren Muhlheim: Right. That’s one of the hardest things to explain to people with fears. They want to bargain that when they’re no longer afraid of it, they’ll do it. The really hard thing is that the only way to not be afraid of something is to do it first. That’s why exposure is so hard, but it works so well.
Chris Sandel: I think one of the ways that I’ve worked on this with clients is to try and move it out of the realm of food – to say, “What are some other things you’ve done in your life that have been challenging, that were anxiety-provoking, but you were able to do?” It could be the classic public speaking, or something along those lines, and someone could say, “I realise there was this other part of my life where I did that, where I did it a number of times and I was able to get over it or get better with it.” Because I think when you’re in an eating disorder, the food side of things can seem so much more monumental and it can start to get in the way of realising, “I’ve done this in other realms.”
Lauren Muhlheim: Yeah, and building is all about – it’s not just exposure, but it’s also building someone’s belief that they can handle it.
Chris Sandel: Also, with acceptance and commitment therapy – and I don’t know if this is the same with CBT – but when they talk about exposure therapy, I think there’s this idea that in classic exposure therapy, it was “As we keep exposing you to this thing, your level of anxiety will neatly come down from a 10 to a 5 to a 3” or whatever, and the goal being that you get to a place where you feel completely comfortable doing that thing.
I think what they talk about with ACT is more, what you’re meant to be doing, as opposed to having that come down, is just learning that despite the uncomfortableness, you can still do that. And if there is a side benefit that it starts to come down – that typically does happen – great, but that shouldn’t be the end goal.
Lauren Muhlheim: Yeah, that’s what the new research about exposure therapy seems to be showing. Exactly what you’re saying. You’ve said it very nicely. [laughs]
00:41:17
Chris Sandel: You’ve written a book called When Your Teen Has an Eating Disorder: Practical Strategies to Help Your Teen Recover From Anorexia, Bulimia, and Binge Eating. obviously, you’re well-versed in this area. What percentage at this stage of your practice is children or teens?
Lauren Muhlheim: Probably I’d say 50% of my practice is teens at this point. The demand for FBT has exploded in the last year with the pandemic. It’s interesting; when I wrote the book in 2018, I was like, “Okay, now I’m going to be getting tons of FBT patients” and they didn’t come. [laughs] I really waited, and it was slow for a long time. And then in the last year, now the demand for FBT has finally arrived. I’m quickly trying to train my staff to be up and running to offer FBT also, because I can’t see everybody myself. I’m doing a lot of FBT right now.
Should we describe what FBT is?
Chris Sandel: Yeah, I was going to say, that would be the thing. What does the acronym FBT stand for, and also give us an understanding of what it is.
Lauren Muhlheim: FBT stands for family-based treatment. It’s sometimes referred to as Maudsley family therapy, and that just reflects the fact that it was originally developed at the Maudsley Hospital in the UK. It’s a treatment that was manualized by Jim Lock and Daniel Le Grange, and it’s a short-term, also primarily behavioural treatment that centralizes the role of parents in supporting their teen’s recovery. It’s used primarily for anorexia but also for bulimia.
It’s an example of task shifting. Task shifting is a model of therapy where you’re training less-trained people to administer the treatment. In this case, the parents are enlisted to do the role of what would often be done by the staff at a treatment centre. Parents are empowered to plan, prepare, serve, and supervise all the meals throughout the day, and in the case of bulimia or when there’s excessive exercise, they would be supervising outside of meals as well to prevent behaviours like purging and exercise.
So it’s a treatment that is very different than traditional treatments, because traditionally parents were often seen as part of the problem of their teen’s eating disorder, and teens were typically removed from the home and sent to treatment centres, and then they came back. So this is really revolutionary in terms of what it’s doing, and it allows teens to stay in the home and to try to get well with less disruption to their lives.
Chris Sandel: With it, is there then still a team that is working with the teen? So they’re then having a separate therapist, and there are other people? Or it is really the family then plays all of those roles?
Lauren Muhlheim: There’s a therapist or clinician guiding the parents and supporting them, and there’s got to be a medical doctor to monitor the teen medically in terms of vitals. But oftentimes, at least in research, that’s the core team. You might pull in other people as needed, but really it’s the parents who are on the ground, in the house, doing the meals.
Chris Sandel: You said originally, after writing the book, there wasn’t as much uptick as you may’ve thought, and now it’s been busier; does a pandemic create the kind of situation that favours doing FBT, because everyone’s in the house and they’re not going out, and the kids are in the house, so it in a sense makes more sense to be doing it in that manner?
Lauren Muhlheim: Yeah. In many cases it was the ideal condition for FBT because no-one wanted to travel, parents didn’t want to send their kids to residential, especially in the early days of the pandemic before medical staff was vaccinated. It was terrifying. I remember families that were really torn about whether to send kids to residential at that point, when in other situations they probably would’ve just sent them, especially when it meant flying and going to different states.
And then, yeah, before the pandemic I remember the struggles of trying to figure out how you were going to get in those meals, and parents would typically go to school, the child would come out, come into the car, eat lunch in the car, and go back in. I remember emphasizing that this needed to be done, and then during the pandemic we had this situation where parents and kids were all home. So it really did make the meal supervision easier for many.
Chris Sandel: With this model, I guess you’re then going to have the parents really being onboard with this, and I imagine also having to eat a lot of meals alongside the children? Given everyone’s favourite pastime of dieting and having issues around food, how much of this is an education from you to the parents? How much of a pushback is there for parents, thinking “Gosh, I don’t know if I can do this”?
Lauren Muhlheim: Parents can be educated pretty quickly. When they realise how sick their child is, they very quickly get onboard with the idea that they need to eat more, and most parents very quickly acknowledge any dieting that they were doing, and many will gain weight right there with their teen. I think a crisis like that is a great opportunity for learning and re-education in the family.
Chris Sandel: How widely accepted is FBT?
Lauren Muhlheim: It’s hard to say. I think it’s becoming more widely accepted. The word seems to be out now. Because it’s evidence-based, it’s well-researched, and it should be the first line that’s offered to a teen who presents with an eating disorder, because it’s an active treatment, like CBT is. It’s actively changing the behaviours; it’s just doing it through the parents requiring the behaviour changes because we assume that many teens with anorexia are not onboard with making behavioural changes. So it’s empowering the parents to require these changes. I really see it as parallel with CBT in many ways.
The research on FBT shows that it’s most effective when applied within the first two years, and it really should be the first line. It’s still sad to me when I see so many families who’ve tried individual therapy for like a year, and then they decide that’s not working and they come to me. I’ve got a couple of families where there’s been no weight gain in a year, and the teen has been malnourished that long. It’s pretty upsetting because in family-based treatment, we want to see four pounds of weight gain in four weeks to know that it’s going to work. And if we don’t see that, then we’re trying to push for a higher level of care, typically.
It should be something that people try first. It still doesn’t seem like it’s the automatic go-to. I think it’s gaining in recognition and people are hearing about it sooner, but I still don’t think that it’s as – and then, of course, there’s not enough providers. So even if parents do learn about it, every FBT provider right now has a waiting list. But hopefully this increased demand will result in more people getting training in it.
Chris Sandel: Yeah. Also, I would say another barrier could be parents’ availability. If you’re saying someone has to go and meet a child at a school gate to feed them lunch, for a lot of parents with a regular job, they may be unable to do that. So for them, doing inpatient is the alternative that appeals because there is no other way.
Lauren Muhlheim: Yeah. I think also sometimes residential treatment is seen as the gold standard, that that’s the best, so I think parents are lured into that sometimes by glossy advertising. Maybe they think that FBT is lesser-than because they’re doing it themselves. But it’s actually more evidence-based.
But there are many ways to do it. I think that that’s, to me, one of the more interesting aspects of it: the creative solutions that each family comes up with look different. I’ve done FBT with many low-income families, because I accept a type of Medi-Cal, which is a county-funded insurance for low-income families in Los Angeles. There are many situations where the school finds someone to supervise the lunch, whether it’s the school nurse or the counsellor or a favourite teacher. I’ve had grandparents fly in from other countries to come help out. I just want to make it clear that it’s not just for those with the most means, but there are creative ways of involving people and getting the supervision done.
Chris Sandel: I am all for it. I think you said there is the glossiness of inpatient, and I’ve worked with many, many, many people who have done inpatient and it really has not worked. I think for inpatient to work, you need to get lucky and get to the right place and have a place that does things in the right way; otherwise, it can really be a disaster. And I know a lot of people who’ve been set back in their recovery because of going to inpatient facilities. So while it’s often sold as the gold standard, I don’t think that that is always the case.
Lauren Muhlheim: Yeah, and especially for teens, especially these younger 11- and 12-year-olds – but I’ve done FBT through the twenties. I think the misconception is that it doesn’t work for older people. But especially when you think about sending 11- and 12-year-olds to residential treatment centres and some of the things that they’re going to be exposed to there, if we can do it in the home, I think it’s so much better.
Chris Sandel: Also, the thing with inpatient is at some point you’re going to have to return to the home, and you’re going to have to learn to do that anyway. And often, with the way that the insurance is, you’re returning out of the inpatient facility not at a place of anywhere near full recovery. You’ve gained some weight, you’ve done some of the important early bits, but you’re still a long ways off. So you then need to start doing that in the home anyway. So yeah, I think you’re right. You can just start from that place to begin with.
I think for me, where I first heard about FBT was through Gwyneth Olwyn and her website that used to be called Your Eatopia about 10 years ago. I think she was talking about it for kids, but then talking about it in a sense of for adults, this is how you need to do it for yourself.
Lauren Muhlheim: Yeah.
00:54:11
Chris Sandel: What about for kids or even teens – are there signs or symptoms or early warning signs that you think people should be looking out for in terms of eating disorders? Or maybe not even an eating disorder, but just changes that could be occurring that could e the precursor to an eating disorder.
Lauren Muhlheim: Important point. Parents will often describe very subtle changes in the early parts, like the teen gave up desserts or stopped coming for snacks. Parents usually think, “Oh, they’re stressed or they’re busy studying.”
Another common early sign is more exercising and increasing their commitment to exercise. These changes are subtle at first, and then they usually escalate, so then they’re not coming for breakfast, or walking a couple hours a day. And because those are behaviours that often look good at first – parents are like, “They want to eat healthier, that’s a good thing” or “Exercise is good for their mood.” So they’re these innocuous behaviours at first, and that’s one of the reasons why eating disorders really sneak in.
Later on, it usually becomes clear that there’s weight loss or mood is really difficult or things are really tense at mealtimes.
Another common but often missed behaviour is obsession with cooking and cooking for other people but not eating it, or watching a lot of cooking shows. Those are some things that parents can watch for.
Chris Sandel: I guess the one in terms of – not necessarily weight loss, but even just slowing of weight and height and all that can sometimes be difficult to spot if it’s in a teen and they’re now at the point where they’re going through their growth spurt, but you’re not seeing it because of the restriction. You’re like, “Oh, maybe they just haven’t hit that point yet” when in fact they should be square in the middle of it, but you’re just not seeing it because of the restriction.
Lauren Muhlheim: Yeah, it makes it so hard.
Chris Sandel: One of the other things – I haven’t looked into the research around this, but it’s something I’ve identified through clients I’ve worked with – for many of them, they remember when they were teens or before the eating disorder started and talk about the fact that they used to eat a lot of food. They naturally, spontaneously consumed more food than the average person, and in the beginning that was something that was completely fine. They didn’t think of it as a bad thing, or they may have even thought of it as a positive in terms of they were able to out-eat their brother or whatever it may be. But at some point that changes, and it’s being seen as a negative.
But it feels like for a lot of people who suffer with eating disorders, their natural propensity is they just need more food than the average person, and when that starts getting restricted, that’s when the switch gets turned on and they fall into the eating disorder.
Lauren Muhlheim: Yeah, I’ve had a lot of teens claim that they were binge eating before they started restricting, and I think it’s just they were probably eating normally, and then they pathologize it looking back. But yeah, it can be a subtle shift from eating what may have seemed like a lot to just less than that.
00:58:13
Chris Sandel: You made a comment before about when doing FBT, you want to see someone put on four pounds in the first four weeks, or whatever the amount is. As part of it, are you using weighing of clients? Are you setting goal weights? Is that how it works?
Lauren Muhlheim: Yeah. With anorexia or when someone is clearly weight suppressed, that’s the immediate target. That’s another area where FBT is like CBT, where we’re prioritising solving the problem as quickly as possible – stopping restriction and getting weight on when someone’s restricted.
The research indicates that four pounds of weight gain in four weeks is prognostically significant, meaning that it’s very tied to whether the treatment is successful. So that’s not an arbitrary thing; that’s based on what the research shows. If you don’t see the early weight gain, then the treatment’s not likely to work. You don’t want to waste a lot of time; you don’t want to keep a teen malnourished for three months with a treatment that’s not working.
Chris Sandel: Do you do the same with your adult clients?
Lauren Muhlheim: So tricky. I find that it’s very, very hard to have an adult gain weight on their own in individual outpatient therapy. I very rarely accept adults with anorexia unless they have meal support because I’ve very rarely had adults who were able to really weight restore with just individual psychotherapy and individual outpatient dietary support. Usually when I see adults, it’s more for bulimia or binge eating, or I’m doing FBT with young adults.
Chris Sandel: That’s interesting to hear. I do work with people who suffer with anorexia and am able to help them put on weight. And the reason I was asking around do you weigh clients is I don’t. If clients want to and we can see that there is some benefit in them doing it, we will, but most of the time I don’t need to. We can start to see things are going in the right direction first by looking at their symptoms, by looking at their food log, by looking at so many other factors that I don’t think the weighing for most people is helpful.
I also have had clients as well who have been given goal weights, and where that then becomes a real problem – because they’re now knocking up against the weight that they were told was going to be the upper limit of their goal weight, and they’re still not recovered. So for me, when I have my initial chat with someone to work out if we’re going to work together, I’m always really blunt around the fact of, “I don’t know where your weight is going to go, and I don’t know where it’s going to end up, and I don’t want to make any promises around that because I’m not in control of that. Your body is in control of what it wants to do as part of healing.”
There’s a part of me that’s like, I can understand in certain circumstances why weighing people can be helpful, and setting some kind of a weight goal, but I see a lot of it causing problems and goal weights being set ridiculously low that guarantee someone is going to continue on with an eating disorder or disordered eating afterwards because there is no amount of recovery that is going to take place by the time they’ve got to that goal weight.
Lauren Muhlheim: Yeah, I think that’s such a challenge. I’ve tried many different things with no goal weights, giving a range, giving a single minimum number. I think any way you do it, there’s potential trouble. With adolescents with anorexia, I definitely weigh them more now that we’re doing the home version. The parents or somebody, the paediatrician, weighs them and sends me the weights, because there would be no way to know with a teen over video whether they’re gaining weight. And probably even in the office, it would be hard to gauge, because so many become hypermetabolic that the parents could be feeding them 4,000 calories a day and they’re still not gaining weight. So I couldn’t just rely on the fact that they’re eating that much to be sure. I think you do have to weigh in that circumstance.
I tend to use growth curves to predict where we think a teen will get healthy. Of course, you can couch it in all the ways that this is just a predictor, but they hear the number – and I feel like it’s helpful to give parents a number because sometimes the parents come to me and the teen’s only lost 5 pounds, but meantime they should’ve gained 20 during that time that they’ve been ill. So then I need to say, “No, this teen has to gain 25 pounds to get back to their growth curve” and the parents are thinking they only have to gain 5 pounds.
Or I think it helps parents know that this teen has to gain at least 10 pounds, this teen has 40 pounds – because they know how long it’s going to take when you say it’s going to be one to two pounds per week. Are we going to be doing this for 5 weeks or 20 weeks? Also to emphasize the need to go faster, because you’ve got a teen who’s got to gain 25 pounds and you’re gaining half a pound a week, it’s going to take year, which is not really a good thing for a teen who’s not menstruating.
So I do find it helpful to give a target range, but then again, when you give a range, then they hear the top number as a number which they should never go over, so then that becomes pathologizing. You give a single number and then they want to stay just beneath it. There’s kind of no good way. I’m struggling with that.
Chris Sandel: I guess the difference as well with you and the teens versus the clients I’m working with – I’m very up front in terms of the services that I’m able to provide, and that we’re having these conversations and we’re talking every two weeks, they’ve got email support, we’re doing it in this manner. And it’s like, if you need a higher level of care, then we are not the right fit. Whereas if someone’s saying, “Yes, I want to do this”, there is already that motivation there. They’re already saying, “Cool, I want to take these steps” – even if there’s still a lot of the eating disorder saying “No, you shouldn’t be doing this.”
If someone’s signing up to work with me, it’s very different to a teen who is going through the FBT, who’s doing it through gritted teeth because their parents are making them do it, and if they are left to their own devices, they’re going to continue full-blown into the disordered behaviour. I think having those two things being different means that there’s different methods that are in place.
Lauren Muhlheim: Right. I rarely weigh adults anymore, and that’s really come from my HAES overlay over CBT.
01:06:05
Chris Sandel: One of the things you mentioned early on was about the ARFID. That’s avoidant-restrictive food intake disorder, if people are wondering what that acronym stands for. It’s something I haven’t chatted about on the podcast before, so do you want to, again, talk about what this is?
Lauren Muhlheim: Sure. ARFID is a diagnosis that only came about in the 2013 Diagnostic & Statistical Manual. Before that, it was a disorder only recognised in younger children. It was in the ‘Feeding Disorders of Childhood’ category. Research on ARFID as the diagnosis that we know it now is pretty new.
ARFID is basically when someone has an eating disorder and they don’t meet their nutritional needs, but it’s not out of a fear of weight gain, as in anorexia. They have complications from not eating enough that either affects them socially or medically or affects their growth. Again, these are people who don’t eat enough, and there’s three types of ARFID that have been identified.
One is sensory sensitivity type, and these are people who are very sensitive to different tastes and textures. They may be supertasters, if you’ve heard of that. They’re often born that way, so they may have other sensory sensitivities, like they may be sensitive to the tags in their clothing, and they may prefer certain textures over others when it comes to food. Because foods have variant tastes in them, they tend to stick to this narrow range of familiar foods, and anything then outside of this narrow range feels very foreign to them. That maintains this narrow range of foods.
Chris Sandel: With that first type, the way you described it there, I can see that there could be overlap in terms of autism with this. I could see there also be overlap with some people who have HSP. So that could be part of this.
Lauren Muhlheim: Yeah, like sensory processing disorders, there’s some overlap, and autism there’s some overlap as well. So that’s the first type.
The second type is low interest type, and this may also start at birth. It may be people who are born with low hunger drive. They’re just not particularly interested in eating. Food is not that rewarding to them. They just don’t get very hungry. These are people who have always had a low appetite, always had trouble keeping weight on. It’s just really an effort to eat enough for these people.
Then the third type is fear of aversive consequences, and this is usually associated with an underlying anxiety disorder, and it usually has a more acute onset later in life. It can be in response to a choking episode in themselves or others, or a stomach flu. And then the person develops a phobia around either fear of vomiting or fear of choking – those are the more typical ones. It could be fear of an allergic reaction to food. This one is more like a phobia and can overlap with a phobia. So you can have a diagnosis of emetophobia (vomiting phobia) and also have the diagnosis of ARFID, and the difference would be that then the person is not eating enough and it’s affecting either their weight or their health or their social interactions.
People who then become afraid of vomiting will develop all kinds of safety behaviours, like they won’t eat to fullness or they won’t eat spicy foods or they won’t eat in the evening, and people who are afraid of choking will often avoid foods that are more chewy and they may start to restrict more and more till they’re only eating a liquid diet. And of course, then there are often medical complications when people start to restrict so much.
Then among the three types of ARFID, often people have more than one. People can have multiple types of ARFID and people can also have ARFID and anorexia, for example. So it gets complicated, and the treatments are a little different.
There’s two main research groups in the US that I’m aware of that are exploring treatments for ARFID, and one is a group at Harvard led by Jenny Thomas and Kamryn Eddy. They have a treatment manual called CBT-AR, CBT for ARFID, and they’ve been collecting research on that treatment. That’s for ages 10 and up.
Then the other group is led by Nancy Zucker at Duke, and her treatment is called FBI: ARFID. It’s Food and Body Investigators: ARFID Division, and it’s this adorable treatment that she’s developed for kids 5 through 9, where she makes them into FBI agents and they become investigators, learning all about the body. She tries to help them reframe sensations and feelings into something to be curious about rather than scared of. She has these little characters. She has all these little illustrations of these very cute characters, like Henry Heartbeat. I can’t remember the names of the others, but to teach kids all about the functions of the body.
Chris Sandel: That’s really cool. That’s a really nice way – I mean, even with adults, so much of the work that I do is like, let’s bring curiosity to this. Let’s have it be an experiment, how to do so in a lighthearted way. Not a lighthearted way, but just take off the pressure of having to do everything right. And I guess it’s the same here, like, let’s learn how to listen to our body and do it in a mindfulness way as opposed to “I’m trying not get rid of this thing or I’m trying to get away from it.” It’s more like, let’s learn how to accept it and explore it and be curious about the sensations.
Lauren Muhlheim: Exactly.
Chris Sandel: It sounds like ARFID is a lot more common where it’s started out from a very young age. In terms of the first two categories that you listed there in terms of low appetite or the sensitivity to tastes and textures, etc., it’s unlikely, or less likely – or maybe I’m wrong about this; you tell me – but someone developing that in their twenties or thirties or forties, and yet they hadn’t had that prior.
Lauren Muhlheim: Yeah, for the first two types it often exists from childhood. But many of these people never got treatment as kids. I’m actually doing a support group for adults with ARFID now. These are people who’ve had this since childhood, and it wasn’t a diagnosis then. Some of them, their parents either didn’t recognise it or didn’t know what to do. Several of them had doctors who minimised it. Some were malnourished for years with ARFID. It’s really just starting to get some recognition. We’re really in the early stages of finding treatment for it.
I was on a call, and Kendra Becker, who works in the Harvard group, was saying that they’re discovering a whole slew of middle-aged onset of ARFID as well, possibly related to menopause changes and GI symptoms that’s causing middle-aged – I think she said women – to not eat enough or to be afraid of eating. So I think we’re just learning more about ARFID.
Chris Sandel: I wonder in terms of the later-in-life part if because of Covid that starts happening. I’ve got a client I used to work with who got in contact to say, “My taste is gone, my smell is gone, and this wasn’t just a short-term thing that happened. It’s gone on for months now.” So I wonder if after that starts to come back, or if it only comes back in small amounts, how that’s going to affect people who’ve had that symptom as part of Covid.
Lauren Muhlheim: So interesting. We may have post-Covid-induced ARFID.
Chris Sandel: The bit about the fact that this has gone on for so many people since birth, and for as long as they can remember, and you’re then catching it in their twenties or thirties – that must be so difficult for some people to then get away from the fact that “Oh, I’m just a picky eater” or “This is just who I am.”
I think often, it’s a struggle with anorexia in terms of that becomes someone’s identity and they really identify as being the thin one or the fit one or whatever. At least with that, you can start to touch into “What was going on before your eating disorder? What were you interested in before then?” and you can start to separate those two things out. But if you’ve got someone who, for the first 30 years of their life, this is all they’ve ever known – is it difficult sometimes to get people to realise that this is a thing, and it is an important thing that they need to get over, and it’s not just who they are?
Lauren Muhlheim: I think many of them are motivated to work on it once they identify it and know that there’s some help. I think some have been more resigned to live as a picky eater. Even the Harvard group shows that for people who have been the sensory sensitivity type, the picky eaters, they say, we’re not going to make them into foodies. The goal is to get them to increase the range of foods, and for health reasons to include more food groups. But they’re not going to develop the biggest palate.
On the other hand, I have a couple of teens who really have developed amazingly big palates, so I wonder – I’m sure with everything there’s a range of how much people can expand. Some will probably always be fairly picky. But I think help for them can really validate that, yes, you have this condition, and it’s a real thing. You’re not just being stubborn or difficult. And it’s okay if you mostly eat chicken nuggets.
Because there’s also a lot of shame in ARFID, and it’s interesting because ARFID is often seen as – because it’s not weight-focused, I think we often think that diet culture doesn’t play in as much. And I’m really seeing that diet culture does play in because people are being shamed when they go out for always ordering chicken strips and French fries and not eating salads. Or just the influence of other family members having not given them one of the things that may have been a good food for this person with ARFID. There’s just so many things to unpack with people who’ve had ARFID for a long time.
01:18:47
Chris Sandel: What is the way of dealing with it? I know you said CBT. Is it similar to what we talked about before in terms of we’re going to keep a food log or awareness log, we’re going to set up challenges where we’re doing exposure therapy? Is it that same kind of model?
Lauren Muhlheim: It’s actually a pretty different treatment. Let’s start with the fear of aversive consequences. That is more a true exposure treatment with an exposure hierarchy, where you make a list of their most feared situations and you go up the ladder, exposing them. So if a person who’s afraid of choking is most afraid of steak and they’re only eating a liquid diet, then you would make a hierarchy of starting with the easiest thing beyond liquids and working the way up to getting them to eat steak. And there might be other things, like eating steak with someone versus eating steak alone. So you can have all these things on the hierarchy.
Oh, and I should preface by saying you always start ARFID with making sure that someone is eating enough. That’s similar to CBT. You want to make sure people are eating regularly because many people with ARFID have given up eating or gone to grazing, and then that further dulls the hunger signals. So you want to put them on a schedule of regular eating regularly throughout the day. If they’re malnourished, you also have to restore them to health as soon as possible.
And you give them permission to do it on their preferred food, whatever that is. So if the child is only eating French fries and pizza, fine. You want to make all their meals foods that they’ll eat.
Chris Sandel: I always say to clients, calories trumps everything else. It’s like, let’s get in enough food. And yes, variety matters, and yes, challenging fear foods matters. But if you’re not doing the calorie side of things or you’re not getting to a good place with that, then getting stuck in the weeds with the other stuff, it’s just not the time to do it.
Lauren Muhlheim: Yeah. The fear of aversive consequences type, like I said, is mostly an exposure hierarchy. You’re doing this outside of meals, so they’re still getting their nutrition and then you’re doing exposures just to eating whatever the fears are. Or feared situations, because people with fear of vomiting may fear being near children or going to school. So you can build other things into the exposure hierarchy.
Chris Sandel: Am I right in thinking that with emetophobia, the fear of vomiting, the last step with that is actually having someone be sick? Is that the last one?
Lauren Muhlheim: No, you don’t have to do it.
Chris Sandel: Okay, fine.
Lauren Muhlheim: [laughs] Are you relieved?
Chris Sandel: No, I’ve had some clients where this has been a thing for them, and I’ve referred out with this part and said, “You can see someone about this if it’s something that’s having a real impact on you.” When I was doing some reading around it, I thought that that was the last one. Or maybe I’m misremembering that.
Lauren Muhlheim: Yeah, no. I mean, I don’t agree that you would have to do that, and most people say you don’t have to. I think you just have to have people do all the things that they are avoiding. It could be eating and then going on a rollercoaster. That could be the top of their hierarchy.
01:22:40
The sensory sensitivity type is actually, I think, really fun to treat. Basically, the core part of this is you give them this huge long food list and you ask them what foods they want to learn about, and for each session, they choose five foods and they bring the foods as they want to try them. You do this very non-pressured exploration of these foods according to the five steps, and you ask them to use non-judgmental language as they tell you what it looks like, what it feels like when they touch it with their hand, what it smells like, and then the last two are after they taste it and chew it and swallow it. The last two are what does it taste like and what does it feel like in their mouths.
You ask them to try two bites of each of these foods, and to answer those questions. Then the goal is to get them to do about 10 trials with each of these foods. So they have to practise during the week on the same foods, any of the ones that they tried that they’re willing to keep trying. You ask them to record the trials, and then after they get to 10 trials, then you ask them, “Is that a food that you are able to incorporate?” If so, you talk to them about how they might incorporate it, like if they tried apples for the first time, would they have a couple slices as part of their snack? Or they could choose they don’t want to keep trying the food, and then you move on to five more foods.
It’s slow at first because these foods are unfamiliar and it could take up to 15 trials before they’ll accept it. For people with ARFID, with this type of ARFID, they’re often just afraid of trying anything new, so the anxiety can be really high. You can start with really low-level foods. With one of my teens, I had to start with Pop-Tarts as a new and novel food that was less threatening than other foods.
They get experience in all these different foods that they’re trying, but they also then get experience just in the experience of trying something new, so they get less scared. Over time, it’s amazing to see that they’ll start to become more confident in trying new foods, and most of the people I work with will report that then they finally have courage to actually try something outside of our sessions. Like they’ll be at an event and they’ll actually try something, and it’s shocking to the family.
But it’s slow because you might try five new foods each week and then two weeks later you’ve added two foods. And the goal is to keep the newer foods in some kind of rotation, and you encourage them to keep incorporating them so they don’t drop off again. You go back maybe through foods that they used to eat but they may have dropped, or foods that are similar to other foods. You try to also expand their flexibility, like if they only have a preferred brand, they’ll only eat one brand of chicken nuggets, you try to see if you can get them to try a different brand of chicken nuggets or from a different restaurant, and expanding that way.
And during the pandemic, these were the families where they were running around – the kid will only eat chicken fingers from this one restaurant or only eat this one brand of mac n cheese, and when food was short and things were crazy during the pandemic, these were parents who were trying really hard just to nourish their children.
Chris Sandel: Yeah, that would be difficult. I was thinking as part of – you said it’s a really slow process. And recovery is slow. When I think about my clients, I think there can be this misconception around recovery from reading people’s recovery stories online or whatever that “I should be done in five months.” And for a lot of people, it just takes a really long time. If it takes that amount of time, it takes that amount of time.
Lauren Muhlheim: And the goal is you get them to the point where they can continue to try new foods on their own, because there’s a whole world of foods. I think in their research, they’ve done about 20 sessions, because they’re also capitated. But that seems to be about a good number. I’ve been counting, and 20 to 25 seems to get the people to a point where they can then continue to try foods on their own.
Chris Sandel: I think by that stage, as you said, you’ve done it enough so that you’ve got over the anxiety of trying new things. And I would also imagine that as time goes on, when you’re tasting that food, you’re able to say, “There’s the sweetness that reminds me of that other food that I tasted, and there’s this texture of this other food” – so it doesn’t feel quite as new because you’re able to recognise it as being similar to these other things.
Lauren Muhlheim: Yeah, and then you can also do chaining. Someone who likes pasta and feta cheese, then you try some recipe that has them together.
01:28:22
Chris Sandel: What about the middle option that you described? Someone just has a low appetite.
Lauren Muhlheim: That’s the hardest. With a kid, you can pretty much do straight FBT and get the parents to get them to increase their volume and get weight on. With adults, I’ve really struggled, and I’ve sought a lot of supervision from the Harvard group, and they say this is also where they struggle. With adults, a lot of very heightened sensitivity to internal bodily sensations that increase anxiety and make it harder to eat. They’re looking into medications. There’s a lot of overlap with GI issues. I was encouraged to do a consult with someone who works in their GI clinic, and they were basically talking about medications that can help.
So I think we don’t have the best answers to that. The treatment in CBT-AR, it’s about trying to get them to push past fullness, to be able to tolerate more fullness, to better tolerate the bodily sensations that come with eating.
And the patients I’ve worked with describe how it’s just so much effort to get themselves to eat enough. Some of them have worked really hard and gained a lot of weight, and they’re still saying, “Does this get easier at a point?” It just requires a tremendous amount of focus. Interestingly, when I’ve given the assessment called the PARDI, which is the pica, ARFID – I don’t know, it’s this assessment that assesses ARFID, and the one question that all the people with ARFID seem to relate to is “I find eating to be a chore.”
I just think about that in terms of the low-interest ARFID. It goes against their biology. For some reason, eating is not rewarding, and it’s a chore. And it requires so much effort. To have to really focus on it and eating enough is really, really challenging.
Chris Sandel: Yeah, that sounds really tough. At least with all the other eating disorders, you’re working with biology in a sense of once you start to eat more food, you get hungrier, you will get to a place of equilibrium. Once you start eating more food, the binges will stop. So it’s working with the body, and as time goes on and health improves and healing improves, it becomes more natural and more easy. But in something like this, you’re talking about the fact that there is something that is going on that is inbuilt, that’s not going to auto-correct. So this is now an ongoing, lifelong thing.
It’s sad when I hear you talk about that because I have a lot of clients who have anorexia who are like, “I wish I had that. I wish I didn’t get hungry.” I’m like, I don’t think you understand what you’re wishing for here.
Lauren Muhlheim: Yeah.
Chris Sandel: With that, would there be medications that are already in existence that are helping with appetite?
Lauren Muhlheim: No. I think we don’t have the answers to that yet. They recommended some medications like for off-label use that calm sensations in the GI system. But they’re studying that there may be hormonal imbalances, that these people may not have enough hunger hormone and the fullness hormone kicks in too early. So maybe there will be treatments on the biological level at some point. But as far as I know, there’s nothing yet.
Chris Sandel: Very much in its infancy. I would be interested to find out, are there genetic abnormalities that are connected to that as well? If from Day 1, someone just didn’t have good hunger feedback.
Lauren Muhlheim: Yeah. Even then, what’s totally biological versus some developmental, like the training I’m doing with Nancy Zucker – she’s looking at some early developmental factors. I’m remembering this slide where she looks at GERD in infants can be a turn-off to eating. The second one is a muscular issue, like a low suck reflex on the baby. Maybe the baby’s not getting enough milk and it kind of gives up. Who knows? And then the third thing on the slide was respiratory issues, and babies who are congested, she says, may choose to breathe over eat.
So who knows whether it’s purely genetic or there’s some very early developmental things that happen that influence it, or more likely some combination.
Chris Sandel: Even in adults with anorexia that I work with, it’s easy enough with enough time to cut the ties between the feeling of hunger and seeing that as a message. You’re like, “I experience these various sensations, but I do not connect them with hunger.” And if that has happened from as long as you can remember, then yeah, it can be very easy to say, “I have no hunger drive whatsoever” because you haven’t made that association.
Lauren Muhlheim: Yeah.
01:34:12
Chris Sandel: The final thing I wanted to ask – you wrote an article for Verywell where you talked about cognitive remediation therapy with anorexia. It was just something I hadn’t heard of before and thought it was quite interesting, so I wanted to have you be able to share it.
Lauren Muhlheim: That’s cognitive remediation therapy, and it’s another exploratory treatment that’s being studied for anorexia. Individuals with anorexia get rigid in their thinking and don’t have cognitive flexibility, so the thought is to try to build their cognitive flexibility, and doing it outside of something about food. So rather than having sessions or trying to push them to eat foods that they’re afraid of, you focus on their brain patterns instead, and try to build flexibility in these innocuous tasks.
When I think of that, I always think of the Wisconsin Card Sort, which is a neuropsych test that at one point I was taught to administer. It’s this card sorting task where you just put out these cards and you don’t explain, and the person has to sort them. They all have different colours and a different number of items and a different type of item on the cards, and you don’t tell them what the rule is. So someone eventually figures out that they’re supposed to sort them according to let’s say colour, and then as soon as they get it right, then you change and they have to sort it by the object on the card.
It takes a while, and people who are very rigid will continue to stick to the colour even though you’ve told them they’re getting it wrong, so they don’t have this flexibility, and that’s this set shifting, a problem in older adults who have dementia or cognitive problems – but the same kind of thing is exhibited in people with anorexia.
And they don’t know if it’s premorbid or if it comes about with the illness, but there’s some research showing that you can train them to be more flexible in their style of thinking. And then the hope is that that would translate to being more flexible around eating.
Chris Sandel: Nice. When I read about it, I was like, that makes a lot of sense because obviously, as you say, it’s rigidity in all aspects of life. It’s not just around food. It’s amazing how much people get into the rituals and the patterns and the OCD type behaviour connected to everything, not just food.
Lauren Muhlheim: Right.
Chris Sandel: In terms of the research, where are they at with it? What have they been able to demonstrate? Or it’s still in its real infancy and they haven’t shown anything?
Lauren Muhlheim: I’m not super up on the research on this. I’ve attended some presentations, and it seems like there’s some early evidence supporting it, but first of all I don’t think it’s ever been a standalone treatment. It would be a supplement. You can’t just do that as the only treatment. But it can’t hurt for families to also do games that involve these types of flexibility, and I think if you were to search for cognitive remediation therapy games, you can come up with activities that can build flexibility. So it can’t hurt to try.
Like I said, I’m not totally up on the research, but I don’t think there’s major studies at this point. But it’s promising enough that they’re continuing to explore it. The bigger thing is it’s not really disseminated yet in a big way. I don’t have a manual that I could start to do it.
Chris Sandel: It at least makes real good, logical sense about why this would be helpful. In a sense, I’ve been trying to do this with clients anyway, where it’s like, let’s see if you can have times where you move round the point at which you’re exercising in the morning, or you have days where you’re not exercising in the morning, or you’re having your snack an hour earlier, or whatever it may be.
So yes, it’s often more focused on the food and movement side of things, but even bringing in new hobbies is part of this as well. Like normally in the afternoon you’re doing this, but now you’re going to start playing guitar or playing drums or playing clarinet or whatever it may be. I think that has the benefit of dealing with the flexibility piece, but also the benefit of we’re now creating more enjoyable things coming into your life, which is in support of “I want to keep recovering because there’s more things that are enjoyable in my life” as opposed to “Everything has fallen by the wayside, and what am I recovering to?”
Lauren Muhlheim: Right. Building the flexibility is important and helpful. So hopefully we’ll learn more about cognitive remediation therapy and be able to incorporate it a little more.
Chris Sandel: Nice. I will definitely be looking out for more research in that area. Thanks for flagging it up and making me aware of it.
Lauren Muhlheim: You’re welcome.
Chris Sandel: This has been wonderful. I think we got to cover a lot of information. I think it’s been very practical in terms of the conversation and what people can take from it. Where should people be going if they’re wanting to find out more about you, Lauren?
Lauren Muhlheim: My website is www.eatingdisordertherapyla.com. I have a lot of articles on there and resources. I’m also the eating disorder expert for Verywell, so one of the articles you referred to is there, and I’ve also written I think 100 or more articles for them on various topics.
Chris Sandel: Nice. I will put all of that in the show notes. Thank you so much for coming on. This has been great.
Lauren Muhlheim: Thanks so much for having me. It was fun.
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