Wendy Oliver-Pyatt MD; Eating Disorders and Diet Culture

Montare Media presents Season 2, episode 6 of the Discover U Podcast: Eating Disorders and Diet Culture

Learn More about Montare Behavioral Health:
 https://montarebehavioralhealth.com/about/digital-library/

JD Kalmenson interviews Dr. Wendy Oliver-Pyatt, MD,  to understand how the rise of eating disorders in our time is related to prevalent shamed based media messages about diet and fitness. Learn about the dynamics of the different ED diagnoses and exciting new developments in their treatment. 

Dr. Wendy is a world-leading expert on treating eating disorders and has been a practicing psychiatrist for more than 25 years. She received her specialty training at New York University-Bellevue Hospital in New York City, and has held faculty positions at New York University, Albert Einstein School of Medicine, and the University of Nevada School of Medicine. Dr. Wendy is Board Certified by the American Board of Psychiatry and Neurology and in both Adult and Addiction Psychiatry.  She is the author of two books, most recently, “Questions and Answers on Binge Eating Disorder, A Guide for Clinicians.” She is a Fellow of the Academy for Eating Disorders and the International Association of Eating Disorder Professionals.  Wendy is the founder of several different treatment centers for Eating Disorders, including Within Health, a comprehensive virtual eating disorder treatment platform, and Galen Hope, a community for integrated wellness, in Coral Gables, Florida. Described by colleagues as warm and wise, Dr. Oliver-Pyatt matches her comprehensive training with an unwavering belief in compassionate and scientifically sound treatment.

Host Kalmenson is the CEO/Founder of Renewal Health Group, a family of addiction treatment centers, and Montare Behavioral Health, a comprehensive brand of mental health treatment facilities in Southern California. Kalmenson is a Yale Chabad Scholar, a skilled facilitator, teacher, counselor, and speaker, who has provided chaplain services to prisons, local groups and remote villages throughout the world. His diverse experience as a rabbi, chaplain, and CEO has inspired his passion and deep understanding of the necessity for effective mental health treatment and long-term sobriety.

Follow JD at JDKalmenson.com

Transcript

JD Kalmenson: 

Welcome to another episode of Discover U, our podcast exploring innovative and effective solutions to issues in mental and behavioral health. I'm JD Kalmenson, CEO of Montare Behavioral Health, a family of dynamic and comprehensive mental health treatment centers in Southern California. I'm honored and excited to introduce you to our amazing guest today and a good friend of Montare, Dr. Wendy Oliver-Pyatt.

Dr. Wendy is a world-leading expert on treating eating disorders and has been in practice more than 25 years. She received her specialty training at New York University Bellevue Hospital and has held faculty positions at New York University, Albert Einstein School of Medicine, and the University of Nevada School of medicine.

Dr. Wendy is a board certified by the American Board of Psychiatry and Neurology in both adult and addiction psychiatry. She's the author of two books, more recently Questions and Answers on Binge Eating Disorder: A Guide for Clinicians. She's a fellow of the Academy for Eating Disorders and the International Association of Eating Disorders Professionals.

Wendy is the founder of several different treatment centers for eating disorders including Within Health, a comprehensive and virtual eating disorder treatment platform, and Galen Hope, a community for integrated wellness in Florida. Described by colleagues as warm and wise, Dr. Oliver-Pyatt matches her comprehensive training with an unwavering belief in compassionate and scientifically sound treatment. Welcome, Dr. Wendy. So happy to have you with us today. 

Wendy Oliver-Pyatt, MD:

Thank you. I'm so happy that you invited me. It's truly my honor and my pleasure. Thank you.

JD Kalmenson: 

And there's no question in my mind that everybody tune in today will walk away with an insight with a new uncovered layer of depth into the eating disorder world and into our optimized living in general. I'll jump right in. People who aren't educated in eating disorders tend to lump them all together. But my understanding is that there are very important distinctions. Can you give us a brief for overview?

Wendy Oliver-Pyatt, MD:

Sure. The main diagnoses that we hear about are, of course, anorexia nervosa, bulimia nervosa and binge eating disorder. However, over the years, we have some new understandings of eating disorders, and we also now have a diagnosis called atypical anorexia nervosa, which I'd be happy to let you know more about so we can understand that a little bit better. And then, also ARFID, which is an avoidant restrictive type of feeding disorder.

JD Kalmenson: 

So binge eating and anorexia are both eating disorders with symptoms being in the very opposite direction, seemingly.

Wendy Oliver-Pyatt:

And I'm glad you made that pause seemingly.

JD Kalmenson:

It's exactly right.

Wendy Oliver-Pyatt, MD:

Because that pause, I think, came up at just a very, very important point in the dialogue. And one of the things that we really deal with in our eating disorder field is the confusion about the underlying dynamics and behavior that fuel all forms of eating disorders and whether or not you have anorexia nervosa, atypical anorexia nervosa, bulimia, or binge eating disorder in some way, shape, or form you're profoundly affected by weight stigma and the society in which we live in that pressures us to pursue a body size and shape that denies our own true biological destiny.

Oftentimes, people think of binging disorder understandably so as a condition that has to do with binging, whereas nothing could be further from the truth to so simplify it as to think it's a condition about binging. So binging is actually, of course, that outward behavior that we see when somebody has binge eating disorder. But what we often fail to recognize are all the underlining variables that set that person up to engage in binging.

So one of those variables oftentimes is shame around eating. And that shame can be deeply embedded and tied to very real stigmatizing issues that have to do with food or other dynamics where shame can actually be firmly embedded. The most common behavior that affects a person with binge eating disorder, the most common behavior that is a prerequisite of binge eating is restriction.

So what happens so often to individuals with binge eating disorder, especially if they've happened to have gained weight due to the binge eating is there is a drift toward assuming that the condition is about binging and taking the mindset that we have to be restrictive, which nothing could be further than the truth because these individuals who are experiencing binge eating disorder very often have deeply embedded shame as mentioned around their need to eat and other, sometimes, other needs as well.

We forget that a need to eat sometimes represents needs in general. So helping somebody become both honoring of, receptive to their need to eat, which actually the irony is that encouraging mindful eating, encouraging attuned eating, encouraging aware, eating is actually a very important component of treating binge eating disorder. In fact, encouraging eating and reducing shame around the need to eat is a very important aspect of treatment of binge eating disorder.

JD Kalmenson: 

That's so eye opening. So for starters, it seems from what you're describing that binge eating and anorexia are not mutually exclusive within the same individual and that they could actually be pivoting from one to the next, because they're both sort of symptoms of a common unhealthy shame associated with eating, in general. Can they be treated

Wendy Oliver-Pyatt, MD:

100%. And it said that about 60% of people with anorexia nervosa convert into binging at some point in the course of their illness. So the idea that there's only one form of eating disorder that any one individual can experience is really not the case. Now, there are some people that do land in one category and remain there. But again, about 60% of the time, people with anorexia nervosa will convert into binging because why is that? The body wants to survive. I always say my dad used to tell me when I was a little girl there ain't no such thing as a free lunch. So I tell the patients that I work with, "You can't get away with all that restriction for free. It's going to catch up with you in one way, shape or form."

JD Kalmenson:

Wow.

Wendy Oliver-Pyatt, MD:

So the body, of course, wants to survive. The body doesn't know what is going on. So there is a drive towards binging in the face of recurrent restrictions. So that's why people are so conflicted about their need to eat because as they start getting exposed to food, it can become very scary, that hunger and that desire to eat.

So somebody with binge eating disorder and somebody with anorexia nervosa, they both may be struggling in a very common way with shame around their need to eat. And what's very powerful in treatment is when somebody with binge eating disorder can see that restrictive person in themselves and somebody with anorexia nervosa can see that part of themselves that's hungering to binge.

Interestingly, when you have the two together in treatment, sometimes, developing compassion for the other person that's suffering from the other condition can actually translate into developing some compassion for these parts of ourselves because a part of this is about pushing down the different parts of ourself and then the way that catches up with us.

JD Kalmenson:

That's unbelievable. So I guess that really answers the next question that I was going to ask you, can they be treated in the same environment, even though they have a lot of similar underlying issues? But nonetheless, their symptoms seem to be so different. So operationally, technically, would you say that they can be treated in the same environment?

Wendy Oliver-Pyatt, MD:

Absolutely. I've been treating them in the same environment since 2003 when I first began. However, I will say that there's some things to keep in mind. And at one time in my professional career, I developed a program specifically for binge eating disorder. And it was just an absolutely beautiful program that we put together. And those who suffer from weight stigma who are living in a larger body who faced that oppression, that constant micro-aggression that society telling them that who you are is not acceptable in some way, shape or form, those kind of traumatic recurrent interactions that get seep into the self, that really creates a very, very difficult dynamic to break out of.

So when I did have my binge eating disorder program, I thought we really found a sweet spot to have all of those patients struggling with that particular form of illness. It was a very powerful and effective milieu that we did put together. And it was something really where profound change happened because part of the healing from that kind of condition if there's associated weight gain, is that it demands of the self a sort of rise above the condition of weight stigma to have an outward looking in mindset about it.

And as a group together, we are able to move people into that place of sort of a higher level of awareness, a higher connection to what really matters and values in their life and self-care and gentleness with yourself. And it really demands of the person to break out of that internalized shame, a perspective that I think in that situation, when we had the group together, it was incredibly powerful.

It doesn't mean that you can't treat the populations together. I'll just share that in my experience this way, I did it at this one point in my career by having the group together. And there was many people living in a larger body who had experienced so much internalized shame from outside that was so deeply embedded into their self that there was something very powerful about bringing everybody together.

JD Kalmenson:

Wow. Wow. So there are pros in either direction. One thing that I'm really wondering about is, yes, they come from so much of the same place. But are there certain factors whether it's genetic or circumstantial that might make somebody more vulnerable to one type of eating disorder over another?

Wendy Oliver-Pyatt, MD:

I do think so. Yes. I mean, even the genetic twin studies show that the highest rate of inheritability is tied to restricting to anorexia nervosa. So we do see some genetic correlations that are high. I mean, among all forms of eating disorders, there's definitely a genetic overlay. But among them, restrictive anorexia has the highest likelihood or the highest risk of presenting with an eating disorder.

And, oftentimes, in restricting anorexia nervosa, we see some temperamental features, which are things such as perfectionism. So we think of perfectionism as like a psychological condition. But we forget that these traits also are inheritable to some extent. So a high propensity towards perfectionism, a high leaning towards what we call harm avoidance, and then co-occurring social anxiety and obsessive compulsive disorder, those kind of conditions lean in the direction of anorexia nervosa restricting.

And oftentimes, with the OCD perfectionism, you'll also find a lot of over-exercise. So restriction with over exercise also wound into that. Of course, our society reinforces exercise. So it's very confusing for people with eating disorders when our society is constantly reinforcing folks to do things that are actually potentially very much part of their condition.

And that's very different from, for example, addictions to substances. You don't go to the doctor when you have an alcohol addiction and receive any positive reinforcement for having a problem with alcohol, whereas you could go to a physician and be in any form of body and be very restrictive. And if you've lost weight, you get a lot of positive reinforcement or if you're exercising a lot, there's an assumption that this is a positive thing.

So it's very confusing, especially when you consider that eating disorders, especially anorexia are conditions where we have what we call poor insight. And insight is actually a cognitive process that has neurobiological correlates. So we don't realize that person with anorexia nervosa with poor insight, it's a neurobiological condition that's getting socially reinforced so often in our society, whether it's at the doctor's office or at the gym or at the school or in the playground, or with family along all domains. Weight loss is generally thought of along the lines as a healthy behavior.

JD Kalmenson:

Well, that's right. And it's such a good point you're making that even with the challenging nature of the field of addiction and chemical dependency, one thing that they have going for them is that there's a certain understanding from society and socially that this is a struggle and that we're going to get you through this. And we know that this is abstinence is what we're striving for. With eating disorder, there's so much mixed messaging. And it's like there's a challenge within a challenge that the challenge is almost that there's no stigma is that we put you on a social pedestal and say, "Look how great you are for engaging in this really dangerous behavior." 

Wendy Oliver-Pyatt, MD:

Exactly.

JD Kalmenson:

It's an excellent point. And we can all do a little bit as individuals, as a society, as communities to help change that a little bit.

Wendy Oliver-Pyatt, MD:

Absolutely. We really have to be careful about the way we overly prize this idea of weight loss and the way we assume that a more slender body is associated with health, because if I took my body as it is and tried to make it any less of a size than it is, I would be restricting my body. I could potentially get social praise. But I would be actually imposing upon myself a very unhealthy and disturbing kind of behavior. And there's just that assumption that we made. 

In fact, I'll tell a kind of a funny story, just for the heck of it. Recently, after the pandemic sort of worn down, I said, "I've been in the house too much. There's a beautiful lifetime fitness that opened up down the street for me." And they have all kinds of really interesting classes. And I was like," I want to lift weights, do Pilates," which I love doing Pilates. They have a swimming pool. I mean, I said, "Why not?"

So I went down there to the gym. And I started doing some classes. I really do want to lift weights. But I want to work with a trainer. But what I realize is that I have such an aversion to working with a trainer because every single time I've ever done that in my life, the first thing out of their mouth is always want to check my weight or want to get out the fat, calibrate or talk to me about my diet. And I almost didn't do it. And then, I just decided, "You know what?" I went to the front desk. I said, "Listen." They probably thought I was nuts, JD, because I said… And there was other people standing around. 

I was like, "I really want to work out with a trainer. But I need to let you know, the trainer cannot bring up weight, food, body fat, nutrition. I promise I know more than whoever you have working here. I promise." And I just kept going. I must have reiterated the statement three or four times. So finally, I was assured that I could just have my time with my trainer without having to experience that.

I always tell my patients, "You have to kind of be a lioness and let out a roar," because there's so much oppression coming in. And it's not that I would be triggered and be sent into an eating disorder at the stage of my life. I'm going there to relax and have a good time. And also, people tend to, once they find out what I do, then, they want to talk about all of that. And I just wanted to have a carefree experience to [inaudible]. So I probably sounded a little nutty.

JD Kalmenson:

No. But it's so important. I mean, what we expose ourselves to is the way we end up thinking. And it's subliminal. And over time, if we're hearing these messages, whether it's in media, social media, from our friends, from our family, it'll trickle in before we even know it.

Wendy Oliver-Pyatt:

Yeah. And I think there's a term that one of my colleagues came up with. And it was called omiteracy versus literacy. What is it that we need to actually omit from our experience. For me, that just wasn't an experience that I wanted to have. And one of the things that also happens in our society is an eating disorder provider, of course, we are sending our patients sometimes to the OB/GYN or the other doctor. And we're constant facing sort of an uphill battle of education toward the providers so that they won't weigh our patients.

And I've had so many times when I tell the providers, if this is my referral, if this is my patient, they have an eating disorder, they don't need to be weighed in your office, there's nothing urgent. And it just time and time, again, people cannot break out of that pattern of you walk in the door of a doctor's office, and

they put you on the scale. So those kind of things you have to help people learn how to defend and protect themselves from.

JD Kalmenson: 

That's amazing. That's amazing. At Montare, we've developed something called a Discovery Model, which basically looks at different causations in other behavioral health arenas, in addiction. And the three general categories or causations are circumstantial or unresolved mental health or chemical imbalances or, lastly, existential or spiritual yearning. And not finding that meaning and purpose leads to a lot of inner turmoil, a void, a vacuum and a feeling of insecurity, or just in general a lack of fulfillment, which can lead us to be unhappy with ourselves and seek mind-altering substances or other unhealthy behaviors. Do you see these three parallels or these three causations as being sources or very instrumental in folks who struggle with eating disorders?

Wendy Oliver-Pyatt, MD:

Yes. When you've shared with me about your model before, I thought it was really very beautiful and very thoughtful. 

One of the things that we have to help people do with eating disorders similar to addictions, and what you're talking about, I think, in your model is helping people get aligned with their values. And I think you talk about helping people find their passion point in a very deliberate way, which I think is really exciting that you really dig into that very quickly.

And I do think that with eating disorders very often, as far as like what your first kind of arm or your second arm, which is talking about the aspects of maybe an underlying psychiatric or mental health condition, I think that's your second, right?

JD Kalmenson:

Right.

Wendy Oliver-Pyatt, MD:

So a lot of times, we see people with underlying OCD, underlying bipolar disorder, underlying social phobia, major depression, very common post-traumatic stress disorder, even if there's not a very obvious trauma. So there's different ways that these underlying psychiatric conditions, mental health conditions when they're not appropriately managed, the eating disorder similar to the addiction, the eating disorder is sort of the way to kind of manage that space and manage that pain that's brought about. So addressing the underlying mental health condition is incredibly important. 

One of the things that I'm super-interested in is epigenetics and intergenerational trauma. So we're getting further, further along and understanding also how vulnerabilities we may be living with vulnerabilities within ourself that's tied to experiences of our ancestors or of people that parented us because epigenetics is epi meaning above genetics. So epigenetics is not about the DNA change like you see in Darwinian evolution. Epigenetics is the way that the DNA differs and how it's expressed. And there are actually ways that parts of the DNA are methylated or different ways that the DNA itself gets expressed that affect how the brain functions that actually is passed on inter-generationally.

So, I being the child of a Holocaust survivor might have been born myself with certain vulnerabilities that were tied to my father's own trauma. Similarly, we can see in our society where there's been inherent racism for generations, the way that brains actually maybe change as related to trauma. So these kind of things, I think, are very vivid when you're working with eating disorders, because it's hardly a time when you treat somebody with an eating disorder at a higher level of care that you don't find some kind of trauma. And you also oftentimes see the intergenerational trauma.

JD Kalmenson: 

Wow. That is so fascinating because ultimately if eating disorder is more often than not, from what I'm understanding, a symptom of some other underlying mental health condition, pinpointing and honing in on what that underlying mental health condition is key and critical to the efficacy of the intervention. It's almost impossible to treat the eating disorder in a vacuum as a self-contained sort of ailment not understanding that it's always going to be tied into something much deeper. 

And this is so important for everybody who's listening to understand that when you talk about eating disorder treatment, we're really talking about mental health treatment and a very deep dive intervention, exploring, understanding what the real challenges are, whether they're trauma, OCD-

Wendy Oliver-Pyatt:

Absolutely.

JD Kalmenson:

... and treating them together with the symptoms.

Wendy Oliver-Pyatt:

Absolutely. Absolutely. And I think one of the things that I often say one of my little one-liners is the person treatment refractory, or are they just not treated? And that's a line I've been saying for a long time, because of time and time again, I see people come in with unaddressed PTSD, or been on Prozac 20 milligrams for three years, and they're still depressed. And there was no medication change. Person needs EMDR, or there's a major family component to what's going on that hasn't been addressed, or there's a psychosocial variable where the kid has ADD, and they're in a school that they're expected to perform in a certain way that is going to leave them chronically feeling like they're coming up short.

So using the domains that you've outlined, I think, are very effective ways of evaluating what's going, along those different domains. And I use, again, the bio-psychosocial or bio-psychosocial spiritual model, which I think dovetails very beautifully with your discovery process that you do.

JD Kalmenson:

Right. How would you say is this different from addiction treatment in the sense that there is a famous couple of schools of thought whether somebody can recover completely from addiction or whether it's a lifelong struggle? When it comes to the world of eating disorder, I know that familiar very vaguely from a sort of layman perspective about recovered versus recovery, maybe you can share a little bit about those two schools of thought. And, obviously, I'd love for you to opine and tell us what your take on that is.

Wendy Oliver-Pyatt:

Oh, thank you so much for asking. That's one of my fun questions. Well, again, one of my one liners, again, is that full recovery is possible when effective treatment is provided. However, I will say that one thing I learned the hard way, and I used to bring people into my center. And I had, in my mind this full recovery bar was everybody I wanted to get to full recovery before they left. And not everybody has the same journey or goes at the same pace.

And every step in the direction toward healing is a very important and worthwhile step. Every step in direction of self-care is a beautiful step. So I don't want my story of being recovered to make somebody who's more living in recovery feel like they're any less progressive than I am. I applaud people who suffer but continue to put one foot in front of the other. 

Not everybody has the same variability. I'm blessed because I did not really face any major psychiatric condition. I don't have OCD or I didn't have severe major depression. So I didn't have any major neuro-biological condition that was really affecting me. That's just one example. I might have had other psychosocial of variables that were very supportive of me in certain ways and in certain times in my life. So, again, everybody's journey is different.

I will say that being the place I am with food, which is at peace with food and probably more so than most American 57-year-old women being very relaxed of food and enjoying my relationship with food, the way that I do considering where I am with that and I do consider myself fully recovered to where I was when I was 15 or 16 years old, where I was thinking about food pretty much all of the time and planning my food and trying to figure out when I would eat or when I would eat or when I would exercise. And that was, really, when you have an eating disorder, it really bombards you. And it's very intrusive experience.

And so, it really takes off wildfire in your mind. And although you may be functioning in many ways, it's a constantly present intrusive experience. And I certainly have had that experience where really there was no waking moment that I didn't have anxiety about food and my weight and what I was going to do to eat or not eat or exercise. That was just on my mind literally 100% of the time. So I know-

JD Kalmenson: 

What's amazing is I'm hearing from you something astonishing, and it just hit me now, based on what we just spoke about a couple of moments ago, which is that the eating disorder is always a symptom of some other underlying mental health condition. It makes so much sense what you're saying now that the whole debate of recovered or versus recovery is way too generic and broad, because what really has to be explored and excavated in the conversation is what's the underlying mental health condition if somebody has a lifelong sort of chemical imbalance? And that will never be cured. It could always be managed. And you could always have coping skills, and you can maintain trying to regulate the symptoms.

But then, the eating disorder will always sort of be lurking in the background as a potential unhealthy mechanism to deal with that underlying mental health condition. But if you're dealing with generational trauma, for example, that you've dealt with and processed, and you've moved on and you've managed to really graduate from that challenge, then recovered completely is definitely going to make so much sense. 

Wendy Oliver-Pyatt:

Right. And I think that even just for myself, a lot of the tools that I learned early on, I got the right kind of perspective early on. I was not, "Thank God, I never joined Weight Watchers." And I never thank God got into Overeaters Anonymous where I was attached to the idea that I couldn't eat carbohydrates and things of that nature.

I moved into the place of learning about what we call intuitive eating or mindful eating, which actually helps really repair the relationship with food from the inside out where there's no good food or a bad food type of mindset. And in that kind of a model, you actually do exposure therapy where you actually do eat a broad range of food and the anxiety around eating over time reduces.

And then, as the anxiety reduces, the mindfulness and the awareness goes up. Of course, that relies on working on underlying shame and other complicated variables. And that doesn't mean that in some harm reduction models, some people might approach their recovery in different ways. But for me and for many of the people that I treat, embracing the principles of intuitive eating and also embracing the principles of health at every size, which means that whatever my body size is, wherever it lands, my focus is on healthy behavior and being gentle with myself, moving my body in ways that make me feel good, caring for myself, eating foods that feel satiating, giving myself permission to embrace and enjoy my relationship with food, regardless of where my body lands.

Maybe, my body will land "overweight" on a BMI chart or not. BMI charts are really unreliable and actually have prejudiced against people who have higher muscular content and so are arbitrarily labeling people as overweight and obese based on the fact that they just may have a different type of body configuration.

So detaching from those "markers" of "health" and being focused on behavior. So we talk about, instead of focusing on weight, we focus on the behavior. So health at every size is about embracing the principles that I deserve to take good care of myself and the ways that are mindful, gentle, and self- preserving, and intuitive/mindful eating is about awakening and embracing my connection to my body, my connection to the cues of both hunger and satiety, eating what I feel hungry for to a point of satiety, and then experiencing that fullness.

All of that, of course, is orchestrated on that beautiful constellation of neurotransmitters and hormones that's known as the brain gut connection, where our body is really designed to give us the answer from within. 

JD Kalmenson: 

I almost see that in the world of the eating disorder, the folks who are really recovered, they're in such a Zen place. They're in such a place of mindfulness. And they're so comfortable in their skin just by virtue of their journey. And it's just such a pleasure to be in that type of ambiance where there's no judgment and there's just such a real, authentic, mindful presence. So it's an amazing aspect of the lifestyle that you see that.

Wendy Oliver-Pyatt:

I will say that having had in eating disorder imposes upon one in order to heal that work toward that having perspective, and having mindfulness as your anchor to where it goes from being something that you have to practice, practice, practice, where it eventually becomes kind of second nature. I'm certainly not always in a state of Zen.

JD Kalmenson But it's definitely more on your mind than an average individual. And you couple that with sort of an intrinsic existential quest for validation affirmation, and not really relying on body image and people, places, or things-

Wendy Oliver-Pyatt:

Absolutely.

JD Kalmenson:

... to give that artificial external form of a validation.

Wendy Oliver-Pyatt:

Right. I call it an addiction to external validation we have to detach from that.

JD Kalmenson:

Yes. There is something very prominent, obviously, in the world of eating disorder. I'm not sure how many of those who are listening today are aware of it. But family-based therapy is sort of a really big topic within the eating disorder treatment. Maybe, you can just briefly describe the family based therapy, what the family's role is with the patient struggling with ED. And then, do you feel that it's possible to have effective treatment for eating disorder without the family's involvement?

Wendy Oliver-Pyatt:

Well, FBT, family-based therapy, is a particular type of intervention. There's obviously family therapy. And then, FBT is specific type of therapy that is very specific as far as what is actually happening in each particular session. And it's generally oftentimes used more for younger adolescents more successfully. The family, in that case, becomes very involved in helping to refeed the person affected by the eating disorder. It can be a very impactful and effective modality of treatment for some patients.

One of the things about FBT that I think is wonderful is the very first session of FBT is really the session where the therapist's job is to rattle the alarm bell to the entire family. And everybody in the family, siblings and both parents are expected to show up. And in that session, it's really this point of the session is Houston, we have a problem. That's really what we're trying to do. So there's something very psychodynamic too about the patient with the eating disorder, having that attuned caregiving response from the entire family.

The entire family is showing up their energy to come to the aid of the person affected by the eating disorder. And then, the family takes on the role of refeeding the child. And it's a very effective form of treatment for many patients but also not effective for many patients. And in the field, unfortunately, there has become this dichotomous perception that FBT is over here, and then psychodynamics are over here. And everybody's supposed to fight about it. And if you're being psychodynamic, you're blaming the family. And if you're just doing FBT, you're ignoring the psychodynamics.

Then, my belief is that you have to pull out both and where the family can be effective in helping to feed the child or the loved one and can be a part of that experience, and it's helpful to do so. We always want to invite the family in, in a way that is effective. 

And one thing that really I want to say is that when we're looking at psychodynamics and we're thinking about how the family of origin, some of the dynamics might affect the eating disorder, it's not in the vein of blame. It's actually how you empower families to have more impact on their loved one.

It's through that lens of compassionate curiosity and being interested in the dynamics and helping people be able to reflect on that, you are able to help family members have actually more, not less, involvement in the healing process and be more connected to their loved one through the process. It does sometimes take a little bit of pain to have to look at yourself and say, "Yeah, well, maybe when I to when I lock the cupboards, that probably wasn't so good for my child or maybe when I, myself, had my own eating disorder, that wasn't so great for my kids to see, or maybe my obsession over healthy food, maybe that did have effect on my loved one." So being able to look at these dynamics at play can really empower the family to have more influence on their person's recovery. It's not to blame. It's to empower and to discover together.

JD Kalmenson: 

That's beautiful. And just, again, to tie this into what you were saying earlier, of course, the psychodynamics and the [FTB] won't necessarily cancel each other rather or not mutually exclusive because you're dealing with the FTB helping with the symptoms, with the actual integration into healthy eating on the symptoms side. And then, the psychodynamics is exploring the underlying mental health conditions and both have a place and a role.

Wendy Oliver-Pyatt: 

Absolutely. And when you're in the act of actually being that parent refeeding your child, there is actually a psychological correlate of that. So you're kind of coaching behavior. But there's something psychologically meaningful about being there and feeding your child in that active way. So every behavior we impose on somebody or that we're doing has the psychological aspect of it. It's not this exclusive one versus the other kind of experience.

JD Kalmenson:

Right. Wow. This is so helpful. I know we're running out of time. Last question.

Wendy Oliver-Pyatt:

I have a few more minutes if you have any other questions that you wanted to cover before we go off. I know I said too, but [crosstalk].

JD Kalmenson:

Perfect. 

How has technology changed care protocols? Can remote or virtual care work for eating disorders? I'm aware that you have a platform. And how do you find the effectiveness of the virtual care versus the in-person work?

Wendy Oliver-Pyatt: 

Thank you so much for asking. Of course, the first and foremost question that I had when coming up with developing a virtual platform is, of course, to make it effective. So we do have an app at Within Health that helps form all the connections between the providers and the patient and the patient's family. So it's using technology to connect people versus disconnect people. So at Within Health, we're able to reach people who otherwise would have no access to treatment and to support treatment.

So there's much more care when people also step down from higher levels of care. So we can interrupt the progression of an eating disorder and help in the step down. How we do it is we do have a multidisciplinary treatment team with the high frequency of individual sessions. Also coupled with group therapies that are very powerful, effective groups, such as DBT, ACT, expressive therapies, family and relations, mindful eating, yoga, movement, all the therapies, all the group therapies that you would have if you actually were in a bona fide treatment program. And then, we have an extensive amount of participation of what we call the care partner.

And I say to staff and our patients that we're lovingly intrusive. So our care partners check to be sure that the food is available in the home. We actually ship the meals that the patient's eating and the supported meal experiences into the home so that there's that group therapy, group eating experience component. So in a virtual situation, one of the things that we know is that even when you're in a brick and mortar, people can hide food and sneak food and things like that. And I've always said to my people that work for me that it's really the quality of the therapeutic relationship that most dictates how things are going, whether it's in virtual or brick and mortar.

And what's really interesting though, is when people are home, it really does require a deeper, deeper, and deeper connection and deeper pursuit of shoring up that part of the self that wants to be healthy. And we know that people may struggle in different ways when they don't have somebody sort of breathing right there over their shoulder. But there's still this group experience of eating and this joint shared partnership that we have what we call care partners to help support people.

Wendy Oliver- Pyatt:

We have a lot of moms in our program that have young kids that can't leave for treatment. We have some people in some rural areas. So we're reaching a lot of people that otherwise would have no access. So it's been a really beautiful thing. We have an alumni program. People going through our program can still have those relationships with one another because of it being a lot easier in a virtual way.

So once they get into that paradigm of recovery, they don't have to lose the relationships that they've had in the brick and mortar. They don't have to translate all the benefits of brick and mortar treatment back into the home environment, because they're actually doing the recovery in the home environment.

JD Kalmenson:

That's so beautiful. So you're providing access to people who otherwise would not be able to do the in-person work themselves. You're providing a continuum of care for folks, even once they finished the bricks and mortar part of their treatment so that the efficacy is so much more enduring and sustainable. And I'm really excited to see what the IRB, what the outcomes look. I mean, this is transformative. It's revolutionary. And it's amazing-

Wendy Oliver-Pyatt:

Thank you so much.

JD Kalmenson:

... that you're at the forefront of that. Wow. What sort of advice would you give to parents on how to raise their kids with a healthy relationship with food, for those who they don't necessarily see their kids struggling with an eating disorder but having discussed what society, social media, all those messages that our children, our adolescent are being bombarded with? I mean, the fact that today we seem to be paying a lot more attention to eating disorders specifically with adolescence, this is talked about. What advice would you tell the parents? Here's what you might be able to do. 

Wendy Oliver-Pyatt:

First, I will say that I wrote a book once. And one of the chapters was preventing eating disorders in children. And I really wished I had now not even had that chapter title, I thought that was a big mistake because we can't always prevent eating disorders. And to just make a chapter title sort of implies, there's a way to actually prevent it. There may or may not be a way to prevent a child from having an eating disorder. But certainly being protective around things happening at the school, not allowing your child to be weighed at school, not allowing that nutrition class that's teaching calorie count to happen to your kid, not being weight focused yourself, not focusing on external values of appearance, but internal values within yourself and within your family, teaching those principles of how to discern information, how to look at something and know whether it's valid or not valid, looking at… talking about just like substance abuse is talked about, just like we try to teach our kids about that, we need to be thinking and teaching about dieting.

Dieting is like a gateway drug. Dieting is a risk factor for the development of eating disorders. So we want to stay away from dieting. We want to talk about the impact of dieting, and we want to instead focus on the principles of mindful eating and encouraging eating, and really, it's encouraging eating that a person is able to eat mindfully. Ellyn Satter has a wonderful for book that has some nice ideas in it, which is the parent, it's a division of responsibility. The parent decides what and when, and the child decides whether and how much. Now, it's not as simple as that. But feeding your children consistently at consistent time so there isn't a sense of scarcity or judgment around eating is one of the very most important things that we can be doing.

JD Kalmenson:

I love that. And the truth is that not only is this preventative, but what you're saying, even if you sort of take a step back from the whole eating disorder, the community, the guidance and the tips of healthy living that you're talking about is universal. It's for everybody not to be focused on that, not to be caught up with that, even if there wasn't some type of disorder that we're trying to stay away from. This is optimized living, not getting caught up in that. So that's amazing.

Wendy Oliver-Pyatt:

Thank you so much.

JD Kalmenson:

Thank you so much, Dr. Wendy, for joining us on the Discovery U Podcast. We truly appreciate you taking the time to share your amazing wisdom with us. How can people find out more about you and the wonderful work that you do?

Wendy Oliver-Pyatt:

Thank you so much. I was going to say to you, I hope you come to Miami again. I was sorry I missed you last time. I definitely would like to show you around my in-person program, Galen Hope, here in Coral Gables. How to find out more is basically just go to our websites of www.withinhealth.com and www.galenhope.com. Galen Hope has some very special ways that we're approaching treatment that's a little bit different. So if people were looking for something a little different in eating disorder care and mental health treatment, that's where you can find information about that. And always, you can send me a DM on my Instagram, which is wendyoliverpyatt.md.

And, yeah , feel free to reach out. I enjoyed this time so much. I love what you're doing. I love your discovery process and all the passion and compassion that's shown by all of the work that you are doing in your programs.

JD Kalmenson:

Thank you. Thank you so much. And thank you, audience, for joining us too. I hope you enjoyed today's wonderful episode of Discover U. At Montare, we want you to know that you're not alone in your journey. To find out more about our innovative and comprehensive treatment programs, you can check us out at montarebehavioralhealth.com as well. And you can find the Discovery U Podcast on iTunes, Spotify, or wherever you get your podcasts. Wishing all of you vibrant health and a safe and serene day. See you next time.